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BACKGROUND/RATIONALE:
A large and growing population of older adults including veterans survives acute critical illness only to become "chronically critically ill," with profound debilitation, lengthy hospitalization, and often permanent dependence on life-sustaining technology. No previous research has focused on the symptom experience during treatment for chronic critical illness (CCI), yet potential sources of suffering for these patients are many. Nor has there been an investigation of the relationship between symptom burden and other important clinical or utilization outcomes of chronic critical illness, although symptom distress is known to predict adverse outcomes in other clinical settings.
OBJECTIVE(S):
The objectives of this study are: 1) to develop a data collection instrument, study manual, and database for use in the study of symptom burden of chronically critically ill patients; 2) to determine the prevalence and characteristics of distressing symptoms during CCI; and 3) to explore the influence of symptom distress on other important clinical and utilization outcomes of CCI. Symptoms found to be prevalent and distressing will be appropriate for targeting by an intervention to improve comfort and associated outcomes.
METHODS:
This is a prospective cohort pilot study of chronically critically ill patients at Mount Sinai Medical Center and the Bronx VA Medical Center. Physical and emotional symptoms were assessed through patient self-reports using the Condensed Form of the Memorial Symptom Assessment Scale. Data were also collected with respect to selected patient attributes and care processes that might influence symptom burden and other outcomes of interest. Prevalence of symptoms and characteristics including symptom-associated distress and frequency were determined. Statistical modeling evaluates associations between symptom burden and selected clinical and utilization outcomes of patients with CCI.
FINDINGS/RESULTS:
A detailed, comprehensive data collection instrument and study manual were completed, piloted, and used for the main data collection. A database was constructed and populated. We screened 87 patients consecutively admitted to the RCU and identified 61 eligible subjects, of whom 50 agreed to participate. Median age of the study subjects was 73 years. Of the cohort, 52 percent were male, 64 percent White, 86 percent resided at home prior to their hospital admission. The primary ICU admitting diagnosis was pulmonary (28%), cardiovascular (14%), neurologic (14%), surgical (34%), other primary diagnoses (12%). Mean length of hospital and ICU stay for the cohort was 20.1 and 56.8 days, respectively. Among the 50 patients, half were liberated from the ventilator. Multiple physical and emotional symptoms were highly prevalent and distressing for these patients; analyses of these data are currently being completed. Eight study patients (16%) died in the hospital. More than half of survivors were discharged to a skilled nursing facility, more than 25 percent went to a rehabiliation facility. Cumulative mortality at three months after treatment for CCI was over 50 percent.
IMPACT:
CCI is a serious health problem for the nation and especially for older adults, including our veterans. Preliminary data suggest that chronically critically ill patients experience multiple, distressing symptoms, with potential impact on a variety of important clinical outcomes. Rigorous study of prevalence, intensity, and impact of symptom distress is a necessary precondition and strong impetus for quality improvement efforts. Data and analyses from this research will provide the evidentiary foundation or development of interventions to improve symptoms and other associated outcomes for this large, growing and highly vulnerable group of patients.
PUBLICATIONS:
None at this time.
DRA:
Aging and Age-Related Changes, Chronic Diseases, Health Services and Systems, Special (Underserved, High Risk) Populations
DRE:
Epidemiology, Diagnosis and Prognosis, Quality of Care, Resource Use and Cost
Keywords:
Access, Long-term care, Patient outcomes, Primary care
MeSH Terms:
none
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