Health-related quality of life of patients with multiple organ dysfunction: individual changes and comparison with normative population

OBJECTIVE: To determine health-related quality of life in medical intensive care patients with multiple organ dysfunction. DESIGN: Prospective, observational study. SETTING: A 12-bed, noncoronary, medical intensive care unit of a university hospital. PATIENTS: Between June 1998 and May 1999, 318 consecutively admitted adult patients with an intensive care unit stay of >24 hrs were studied. MEASUREMENTS AND MAIN RESULTS: Health-related quality of life was assessed using a generic instrument, the Medical Outcomes Study Short Form-36 Health Survey, at admission and at 6-month follow-up. Patients who developed multiple organ dysfunction (n = 170) consumed 85% of the therapeutic activity provided in the intensive care unit. Compared with age- and sex-adjusted general population controls, multiple organ dysfunction patients had a worse preadmission health-related quality of life than other intensive care unit patients, predominantly due to a higher burden of comorbid disease. In a multivariate analysis, multiple organ dysfunction was the only variable independently associated with deteriorated physical health domains at follow-up (odds ratio, 4.4; 95% confidence interval, 1.3-14.6; p =.015), but it had no impact on dimensions of mental health. Analyzing the impact of different organ system failures, respiratory failure (odds ratio, 4.1; 95% confidence interval, 1.6-10.3; p =.002) and acute renal failure (odds ratio, 3.3; 95% confidence interval, 1.0-11.5; p =.05) increased the risk of deteriorated physical health at follow-up. No impact of the various organ system failures on mental health was noted. At 6-month follow-up, 83-90% of survivors had regained their previous health-related quality of life, and 94% were living at home with their families. CONCLUSIONS: This study has shown that preadmission health-related quality of life of our medical, noncoronary patients was substantially reduced compared with a matched general population. This demonstrates the need to take prehospitalization health-related quality of life into account when examining the outcomes of intensive care unit survivors. Multiple organ dysfunction was the major determinant of poor physical health at follow-up, but it had no impact on mental health domains.     

Long term outcome after delirium in the intensive care unit

Aims and objectives. This research studied the long term outcome of intensive care delirium defined as mortality and quality of life at three and six months after discharge of the intensive care unit. Background. Delirium in the intensive care unit is known to result in worse outcomes. Cognitive impairment, a longer stay in the hospital or in the intensive care unit and a raised mortality have been reported. Design. A prospective cohort study. Methods. A population of 105 consecutive patients was included during the stay at the intensive care unit in July–August 2006. The population was assessed once a day for delirium using the NEECHAM Confusion Scale and the CAM‐ICU. Patients were visited at home by a nurse researcher to assess the quality of life using the Medical Outcomes Study Short‐Form General Health Survey at three and six months after discharge of the intensive care unit. Delirious and non delirious patients were compared for mortality and quality of life. Results. Compared to the non delirious patients, more delirious patients died. The total study population discharged from the intensive care unit, scored lower for quality of life in all domains compared to the reference population. The domains showed lower results for the delirious patients compared to the non delirious patients. Conclusions. Mortality was higher in delirious patients. All patients showed lower values for the quality of life at three months. The delirious patients showed lower results than the non delirious patients. Relevance to clinical practice. Nurses are the first caregivers to observe patients. The fluctuating delirious process is often not noticed. Long term effects are not visible to the interdisciplinary team in the hospital. This paper would like to raise the awareness of professionals for long term outcomes for patients having experienced delirium in the intensive care unit.     

The functional outcome and quality of life of children after admission to an intensive care unit

OBJECTIVE: To evaluate the long-term outcome of children following admission to a paediatric intensive care unit. DESIGN: Prospective, long-term follow-up study. SETTING: Sixteen-bed multi-disciplinary paediatric intensive care unit in a free-standing, university, tertiary, teaching hospital. PATIENTS: All children consecutively admitted to the paediatric intensive care unit from 1(st) January, 1995, to 31(st) December, 1995. INTERVENTIONS: Outcome was evaluated, by telephone interview, at a median of 3.5 years (range 2.3-6 years) after admission to the intensive care unit using a modification of the Glasgow Outcome Score (GOS) to assess functional outcome and the Health State Utility Index (Mark 1) to assess quality of life. MEASUREMENTS AND MAIN RESULTS: Of the children admitted to the intensive care unit, 83.8% were alive at the time of follow-up. While 10.3% of the survivors had an unfavourable outcome and were likely to live dependent on care, 89.7% had a favourable outcome and were likely to lead an independent existence. Although 16.4% had an unfavourable quality of life, 83.6% of the children survived with a favourable quality of life. At the time of follow-up, 16.2% of the children were dead: 49% died in the intensive care unit, 5% died in hospital and 46% died after discharge from hospital. CONCLUSIONS: The majority of children admitted to a paediatric intensive care unit survive with an excellent functional outcome and quality of life. Long-term outcome assessment provides a basis for observing trends in outcome over time within the same institution.     

Factors associated with nurse assessment of the quality of dying and death in the intensive care unit

OBJECTIVE: To determine the feasibility of using nurse ratings of quality of dying and death to assess quality of end-of-life care in the intensive care unit and to determine factors associated with nurse assessment of the quality of dying and death for patients dying in the intensive care unit. DESIGN: Prospective cohort study. SETTING: Hospital intensive care unit. PATIENTS: 178 patients who died in an intensive care unit during a 10-month period at one hospital. INTERVENTIONS: Nurses completed a 14-item questionnaire measuring the quality of dying and death in the intensive care unit (QODD); standardized chart reviews were also completed. MEASUREMENTS AND MAIN RESULTS: Five variables were found to be associated with QODD scores. Higher (better) scores were significantly associated with having someone present at the time of death (p <.001), having life support withdrawn (p =.006), having an acute diagnosis such as intracranial hemorrhage or trauma (p =.007), not having cardiopulmonary resuscitation in the last 8 hrs of life (p <.001), and being cared for by the neurosurgery or neurology services (p =.002). Patient age, chronic disease, and Glasgow Coma Scale scores were not associated with the 14-item QODD. Using multivariate analyses, we identified three variables as independent predictors of the QODD score: a) not having cardiopulmonary resuscitation performed in the last 8 hrs of life; b) having someone present at the moment of death; and c) being cared for by neurosurgery or neurology services. CONCLUSIONS: Intensive care unit nurse assessment of quality of dying and death is a feasible method for obtaining quality ratings. Based on nurse assessments, this study provides evidence of some potential targets for interventions to improve the quality of dying for some patients: having someone present at the moment of death and not having cardiopulmonary resuscitation in the last 8 hrs of life. If nurse-assessed quality of dying is to be a useful tool for measuring and improving quality of end-of-life care, it is important to understand the factors associated with nurse ratings.     

Five-year survival, quality of life, and individual costs of 303 consecutive medical intensive care patients--a cost-utility analysis

OBJECTIVE: To assess long-term survival, health-related quality of life, and associated costs 5 yrs after discharge from a medical intensive care unit. DESIGN: Prospective cohort study. SETTING: Medical intensive care unit of a German university hospital. PATIENTS: Three hundred and three consecutive patients with predominantly cardiovascular and pulmonary disorders admitted between November 1997 and February 1998 with an intensive care unit length of stay >24 hrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, simplified Therapeutic Intervention Scoring System, and individual intensive care unit and hospital costs were prospectively recorded. Primary outcomes included 5-yr survival, functional status, health-related quality of life (Medical Outcome Short Form, SF-36), effective costs per survivor, and costs per life year and per quality-adjusted life year gained.Of 303 patients, 44 (14.5%) died in the hospital. Among the remaining 259 patients, 190 (73%) survived the 5-yr follow up and 173 patients (91%) completed the questionnaire. Baseline demographics including gender, age, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, simplified Therapeutic Intervention Scoring System, and admission diagnosis were similar between hospital and long-term survivors (p > .05 for all). The health status index of those patients surviving the 5-yr follow-up was 0.88, independent of patients' severity of illness. The average effective costs per survivor were 8.827 for intensive care unit costs and 14.130 for intensive care unit and hospital costs. Mean costs per life year and per quality-adjusted life year gained amounted to 19.330 and 21.922 , respectively. Increasing severity of illness was associated with higher costs. CONCLUSIONS: Considering the severity of illness and the patients' outcome, the costs associated with both life year and quality-adjusted life year gained were within generally accepted limits for other potentially life-saving treatments.     

Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit.

BACKGROUND: Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff. OBJECTIVE: To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows. METHODS: During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes. RESULTS: Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02). CONCLUSIONS: In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.     

Role of preexisting disease in patients' perceptions of health-related quality of life after intensive care

OBJECTIVES: To find out how patients perceive their health-related quality of life after they have been treated in an intensive care unit and whether preexisting disease influenced their perception. DESIGN:: Follow-up, quantitative, dual-site study. SETTING: Combined medical and surgical intensive care units of one university and one general hospital in Sweden. PATIENTS: Among the 1,938 patients admitted, 562 were considered eligible (>24 hrs in the intensive care unit, and age >18 yrs). The effect of preexisting disease was assessed by use of a large reference group, a random sample (n = 10,000) of the main intake area of the hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During 2000-2002, data were collected from the intensive care unit register and from a questionnaire mailed to the patients 6 months after their discharge from hospital. Subjects in the reference group were sent postal questionnaires during 1999. Of the patients in the intensive care unit group, 74% had preexisting diseases compared with 51% in the reference group. Six months after discharge, health-related quality of life was significantly lower among patients than in the reference group. When comparisons were restricted to the previously healthy people in both groups, the observed differences were about halved, and when we compared the patients in the intensive care unit who had preexisting diseases with subjects in the reference group who had similar diseases, we found little difference in perceived health-related quality of life. In some dimensions of health-related quality of life, we found no differences between patients in the intensive care unit and the subjects in the reference population. CONCLUSIONS: Preexisting diseases significantly affect the extent of the decline of health-related quality of life after critical care, and this effect may have been underestimated in the past. As most patients who are admitted to an intensive care unit have at least one preexisting disease, it is important to account for these effects when examining outcome.     

Medical futility: predicting outcome of intensive care unit patients by nurses and doctors--a prospective comparative study

OBJECTIVE: First, to assess the pattern of the prediction of intensive care unit patients' outcome with regard to survival and quality of life by nurses and doctors and, second, to compare these predictions with the quality of life reported by the surviving patients. DESIGN: Prospective opinion survey of critical care providers; comparison with follow-up for survival, functional status, and quality of life. SETTING: Six-bed medical intensive care unit subunit of a 1,000-bed tertiary care, university hospital. PATIENTS: All patients older than 18 yrs, admitted to the medical intensive care unit for >24 hrs over a 1-yr period (December 1997 to November 1998). INTERVENTIONS: Daily judgment of eventual futility of medical interventions by nurses and doctors with respect to survival and future quality of life. Telephone interviews with discharged patients for quality of life and functional status 6 months after intensive care unit admission. MEASUREMENTS AND MAIN RESULTS: Data regarding 521 patients including 1,932 daily judgments by nurses and doctors were analyzed. Disagreement on at least one of the daily judgments by nurses and doctors was found in 21% of all patients and in 63% of the dying patients. The disagreements more frequently concerned quality of life than survival. The higher the Simplified Acute Physiology Score and the longer the intensive care unit stay, the more divergent judgments were observed (p <.001). In surviving and dying patients, nurses gave more pessimistic judgment and considered withdrawal more often than did doctors (p <.001). Patients only rarely indicated bad quality of life (6%) and severe physical disability (2%) 6 months after intensive care unit admission. Compared with patients' own assessment, neither nurses nor doctors correctly predicted quality of life; false pessimistic and false optimistic appreciation was given. CONCLUSIONS: Disagreement between nurses and doctors was frequent with respect to their judgment of futility of medical interventions. Disagreements most often concerned the most severely ill patients. Nurses, being more pessimistic in general, were more often correct than doctors in the judgment of dying patients but proposed treatment withdrawal in some very sick patients who survived. Future quality of life cannot reliably be predicted either by doctors or by nurses.     

The 2000 Clinical Research Award. Describing and predicting distress and satisfaction with life for burn survivors

We investigated ratings of emotional distress and satisfaction with life at discharge from the hospital and at a 6-month follow-up in a multisite sample of 295 adults hospitalized for the care of a major burn injury. Several psychosocial variables (history of alcohol abuse, marital status, and previous mental health) and some medical variables (days of intensive care, pulmonary complications, and hand burns) accounted for significant variance in the prediction of outcomes. Brief Symptom Inventory (distress) scores were higher and Satisfaction With Life Scale scores were significantly lower than those of a normative population at both measurement points. The results show the utility of biosocial models in which psychological and physical variables interact to influence adjustment and quality of life.     

Intensive care decision making in the seriously ill and elderly

OBJECTIVE: To determine the influence of self-reported preadmission quality of life, hypothetical quality of life and mortality prognosis, and length and intensity of intensive care on decision making in the seriously ill and elderly. DESIGN: Prospective cohort study. SETTING: Medical university. SUBJECTS: Adult inpatients with chronic illness and an estimated 50% 6-month mortality along with patients > or =80 yrs old with an acute illness. INTERVENTIONS: Patients were presented with two scenarios: a) mechanical ventilation for 14 days; and 2) mechanical ventilation for 1 month with tracheostomy and feeding tube placement. A modified time trade-off was used to vary survival and quality of life over plausible ranges. Patients could consent to intensive care or choose care directed at comfort measures. MEASUREMENTS AND MAIN RESULTS: Fifty patients were interviewed. As projected intensive care unit mortality rate or postintensive care unit quality of life decreased, patients were less likely to consent to intensive care. Postintensive care quality of life was as important to patients as intensive care survival estimates. However, prehospitalization quality of life did not significantly influence decision making regarding life-extending treatment. When progressing from the acute intensive care scenario to chronic mechanical ventilation with associated interventions, patients demanded a significant increase in survival and quality of life. Neither race nor previous intensive care unit admission was associated with consent to intensive care. CONCLUSIONS: There is wide variation in preference for aggressive care that does not appear to be influenced by prehospitalization quality of life. However, predicted quality of life appears to be as important as estimates of intensive care unit survival in decision making. When confronted with extended mechanical ventilation and associated care, a significant proportion of patients would accept this care only for an improved prognosis. Length and intensity of intensive care should be incorporated into discussions regarding intensive care.     

Health-related quality of life before, 1 month after,and 9 months after intensive care in medical cardiovascular and pulmonary patients

OBJECTIVE: Assessment of health-related quality of life before, 1 month after, and 9 months after an intensive care unit stay using an established generic instrument, the Medical Outcome Survey Short Form-36 (SF-36). DESIGN: Prospective, observational study. SETTING: University hospital medical intensive care unit. PATIENTS: Two hundred forty-five patients with predominantly cardiovascular and pulmonary disorders. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, Simplified Acute Physiology Score (SAPS) II, and Sepsis-Related Organ Failure Assessment (SOFA) were obtained. All adult survivors staying in the intensive care unit for >24 hrs were eligible. Pre-intensive care unit status was obtained for 245 patients (179 males, mean age 64 yrs, mean intensive care unit stay 3 days, SAPS II 26 +/- 10), and 153 patients completed all three questionnaires. In this cohort, none of the eight health dimensions of the SF-36 showed impaired functioning after 9 months compared with baseline values. Physical and emotional role deteriorated after 1 month but returned to baseline thereafter. Notably, the mental health summary scale did not change during the course of the study, whereas the physical health summary scale consistently improved over time. Patients older than the median of 66 yrs rated their physical functioning lower. No association with SAPS II or SOFA and SF-36 was found. CONCLUSION: Quality of life after intensive care unit is a dynamic process, with some functions improving shortly after intensive care unit discharge and others deteriorating but returning at least to baseline values later on. In this patient population, the SF-36 was independent from measures of severity of illness or morbidity. Health-related quality of life represents a feasible method to collect patients' individual views in contrast to surrogate measures of outcome.     

Carriage of methicillin-resistant Staphylococcus aureus,ceftazidime-resistant Gram-negative bacilli,and vancomycin-resistant enterococci before and after intensive care unit admission

OBJECTIVE: To measure patients' risk for acquiring antibiotic-resistant microorganisms associated with intensive care unit admission. DESIGN: Prospective, observational study. SETTING: Ten public hospitals including one university medical center. PATIENTS: Consecutive patients admitted to ten intensive care units. INTERVENTIONS: Serial patient surveillance cultures were screened for vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus (MRSA), ceftazidime-resistant Gram-negative bacilli (CR-GNB), Acute Physiology and Chronic Health Evaluation II score, and antibiotic and medical device exposures. MEASUREMENTS AND MAIN RESULTS: A total of 1,697 patient admissions in ten intensive care units were enrolled. The overall carriage rate of antibiotic-resistant bacteria at intensive care unit entry was 12.1% for MRSA, 14% for CR-GNB and 4.7% for both. At discharge from the intensive care unit, new carriage of MRSA, CR-GNB, and both was found in 11.1%, 14.2%, and 2.4% of the patients, respectively. The acquisition rates in the individual units correlated highly and positively with proportion of patients with carriage at intensive care unit entry for both MRSA (n = 10, Pearson's r =.89, p < 0.001) and CR-GNB (n = 10, Pearson's r =.92, p < 0.001). By logistic regression, severity of illness (odds ratio, 1.4), length of stay (odds ratio, 1.7), use of penicillins (odds ratio, 1.9), and number of antibiotics (odds ratio, 1.2) and medical devices (odds ratio, 1.2) were independently associated with intensive care unit acquisition of MRSA. In comparison, variables independently associated with intensive care unit acquisition of CR-GNB were Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.5), number of antibiotics (odds ratio, 1.1), and artificial airway (odds ratio, 1.5). CONCLUSIONS: These data suggest that hospitalization in the intensive care unit introduces significant risk to patients in terms of transmission of MRSA and/or CR-GNB. This risk seems to be influenced strongly by the proportion of patients with colonization at intensive care unit admission and is associated with severity of illness, length of stay, and exposures to antibiotics and medical devices.     

Effects of prolonged intensive care unit stay on quality of life and long-term survival after transthoracic esophageal resection

OBJECTIVE: There are few prospective data on the effects of prolonged intensive care unit stay on the quality of life and long-term survival of a homogeneous patient population. Therefore, the aims of this prospective study were a) to describe the quality of life in patients after having a transthoracic esophageal resection; and b) to analyze the influences of a prolonged intensive care unit stay on quality of life and survival in patients after esophageal cancer resection who survived to hospital discharge. DESIGN: Prospective study. SETTING: Medical center. PATIENTS: The study population consisted of 109 patients undergoing a transthoracic resection for adenocarcinoma of the middistal esophagus or gastric cardia between April 1994 and February 2000. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A comparison was made between patients staying or=6 days in the intensive care unit and also or=14 days. Quality of life was assessed in all patients by mailed self-report questionnaires at baseline (preoperatively), at 5 wks, and at 3, 6, 9, 12, 18, 24, 30, and 36 months after surgery. Daily physical, emotional, and social functioning was assessed with the generic Medical Outcome Studies Short Form-20. Disease-specific quality of life was measured by an adapted Rotterdam Symptom Check List. Quality of life data were gathered between July 1994 and March 2003. Five of the 109 patients died in the hospital and were excluded from the analysis. All five of them were in the intensive care unit >or=6 days. Of the remaining 104 patients, 92 provided baseline scores. The data of the 92 patients were used for the quality of life analyses. For the clinicopathologic and survival analysis, the data of 104 hospital survivors were used. Patients spent a median of 5.5 days (range 0-71) in the intensive care unit. The Medical Outcome Studies Short Form-20 and the Rotterdam Symptom Check List measurements showed no clear differences in long-term quality of life between patients after a short vs. a prolonged postoperative intensive care unit period. The median overall survival in all patients was 2.0 yrs (range 0.1-8.0). Median overall survival in patients staying in the intensive care unit or=6 days (p = .9, log-rank test). Median overall survival in patients staying in the intensive care unit or=14 days (p = .74, log-rank test). CONCLUSIONS: For patients who survived to hospital discharge after transthoracic esophagectomy, there was no difference in long-term quality of life or survival between those submitted to the intensive care unit for a short period vs. a long period.     

Exposure to high stress in the intensive care unit may have negative effects on health-related quality-of-life outcomes after cardiac surgery

OBJECTIVE: Up to 20% of patients do not show improvements in health-related quality of life (HRQL) after cardiac surgery, despite apparently successful surgical procedures. We sought to determine whether failed improvements in HRQL after cardiac surgery are associated with the development of traumatic memories and chronic stress states as a result of high perioperative stress exposure. DESIGN: Prospective cohort study. SETTING: A 10-bed cardiovascular intensive care unit of a tertiary care university hospital. PATIENTS: A total of 148 cardiac surgical patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The patients were evaluated for traumatic memories from postoperative treatment in the cardiovascular intensive care unit (defined as the subjective recollection of pain, respiratory distress, anxiety/panic, and nightmares), symptoms of chronic stress, including those of posttraumatic stress disorder, and HRQL preoperatively (at baseline) and at 6 months after cardiac surgery. A state of chronic stress was defined as the development of posttraumatic stress disorder at 6 months after surgery. Factors predicting the decline in HRQL were determined by multivariable linear regression. Twenty-seven patients (18.2%) had posttraumatic stress disorder at 6 months after cardiac surgery; seven of these patients (4.8%) had evidence of preexisting posttraumatic stress disorder before undergoing cardiac surgery. Patients with new posttraumatic stress disorder at 6 months after cardiac surgery had a significantly higher number of traumatic memories from postoperative treatment in the cardiovascular intensive care unit (p =.01). A multiple regression model included the number of traumatic memories from the intensive care unit and stress symptom scores at 6 months after heart surgery as predictors for variations in physical HRQL outcome scores (R2 =.30, p <.04). Stress symptom scores were the most significant predictors of mental health HRQL outcomes (R2 =.52, p <.01). CONCLUSIONS: Exposure to high stress in the cardiovascular intensive care unit can have negative effects on HRQL outcomes of cardiac surgery.     

Costs of care, long-term prognosis and quality of life in patients requiring renal replacement therapy during intensive care

OBJECTIVE: To assess (1) the long-term outcome of patients requiring renal replacement therapy (RRT) in terms of 6-month and 5-year mortality, (2) quality of life and (3) costs of the intensive care. DESIGN: A retrospective observational cohort study. SETTING: Twenty-three-bed multidisciplinary intensive care unit (ICU) in a tertiary care center. PATIENTS AND PARTICIPANTS: Out of 3,447 intensive care patients admitted, 62 patients with no end-stage renal failure required RRT. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The incidence rate of acute renal failure (ARF) was 8/100,000 inhabitants/ year. The majority of patients (71%) had ARF in conjunction with multiple organ failure. The mortality in the ICU and in the hospital was 34 % and 45%, respectively. Mortality was 55% at 6 months and 65 % at 5 years. Renal function recovered in 82 % of the survivors during hospitalization. Loss of energy and limitations of physical mobility assessed by Nottingham Health Profile were the most frequently reported complaints at 6 months. Functional ability, as assessed by the Activities of Daily Living score was fairly good at 6 months. The cost per ARF 6-month survivor was $80,000. CONCLUSIONS: There was only a minor increase in mortality after discharge from hospital among patients treated for ARF in intensive care. The costs related to ARF in intensive care are high, but the almost complete physical and functional recovery seen in ARF survivors should be noted in cost-effective analyses.     

Patients' perceptions of and emotional outcome after intensive care: results from a multicentre study

Background: Recovery from critical illness can be prolonged and can result in a number of significant short‐ and long‐term psychological consequences. These may be associated with the patient's perception of the intensive care experience. Aim: The aims of the study were to assess patients' perceptions of their intensive care unit (ICU) experience and the effect of these on anxiety, depression and post‐traumatic stress up to 6 months after discharge. Method: One hundred and three participants were recruited from six ICUs from one Critical Care Network in the United Kingdom. A prospective, longitudinal study was designed to assess anxiety, depression, post‐traumatic stress symptomatology and patients' perceptions of their intensive care experience. Data were collected on three occasions: after intensive care discharge and before hospital discharge, and 2 months and 6 months later. Measures included the impact of events scale, hospital anxiety and depression scale and intensive care experience questionnaire. Results: Anxiety, depression, avoidance and intrusion scores did not significantly reduce over time. At hospital discharge there was a significant association between patients' perceptions of their intensive care experience and anxiety, depression, avoidance and intrusion scores at hospital discharge. Conclusion: Standardised assessment of an intensive care experience is important. It provides information about the patient experience which can inform care practice within ICU, following discharge to the ward and, in the longer term, rehabilitation.     

Conscientiousness in Depression: Tendencies, Predictive Utility, and Longitudinal Stability

This study examined the association between conscientiousness and psychiatric symptomatology in a clinical sample, the stability of conscientiousness over a 6-month period, and the incremental utility of conscientiousness scores in accounting for variance in psychiatric symptomatology. Sixty-three depressed patients were assessed following inpatient discharge and at 6-month follow-up. Our sample scored 1 standard deviation below the normative mean on conscientiousness at discharge and at 6-month follow-up, with evidence of significant stability over time. However, substantial volatility in conscientiousness scores at 6-month follow-up was noted among patients with high conscientiousness scores at discharge. Conscientiousness had incremental utility in predicting depression scores at 6-month follow-up beyond the effects of social support, life stressors, and general psychiatric symptomatology. The integration of conscientiousness with current conceptualizations of depression is presented.     

Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates

OBJECTIVE: To determine whether the introduction of an intensive care unit-based medical emergency team, responding to hospital-wide preset criteria of physiologic instability, would decrease the rate of predefined adverse outcomes in patients having major surgery. DESIGN: Prospective, controlled before-and-after trial. SETTING: University-affiliated hospital. PATIENTS: Consecutive patients admitted to hospital for major surgery during a 4-month control phase and during a 4-month intervention phase. INTERVENTIONS: Introduction of a hospital-wide intensive care unit-based medical emergency team to evaluate and treat in-patients deemed at risk of developing an adverse outcome by nursing, paramedical, and/or medical staff. MEASUREMENTS AND MAIN RESULTS: We measured incidence of serious adverse events, mortality after major surgery, and mean duration of hospital stay. There were 1,369 operations in 1,116 patients during the control period and 1,313 in 1,067 patients during the medical emergency team intervention period. In the control period, there were 336 adverse outcomes in 190 patients (301 outcomes/1,000 surgical admissions), which decreased to 136 in 105 patients (127 outcomes/1,000 surgical admissions) during the intervention period (relative risk reduction, 57.8%; p <.0001). These changes were due to significant decreases in the number of cases of respiratory failure (relative risk reduction, 79.1%; p <.0001), stroke (relative risk reduction, 78.2%; p =.0026), severe sepsis (relative risk reduction, 74.3%; p =.0044), and acute renal failure requiring renal replacement therapy (relative risk reduction, 88.5%; p <.0001). Emergency intensive care unit admissions were also reduced (relative risk reduction, 44.4%; p =.001). The introduction of the medical emergency team was also associated with a significant decrease in the number of postoperative deaths (relative risk reduction, 36.6%; p =.0178). Duration of hospital stay after major surgery decreased from a mean of 23.8 days to 19.8 days (p =.0092). CONCLUSIONS: The introduction of an intensive care unit-based medical emergency team in a teaching hospital was associated with a reduced incidence of postoperative adverse outcomes, postoperative mortality rate, and mean duration of hospital stay.