By Betty Tran MD MSc, Editor
SYNOPSIS: In this prospective, longitudinal study of adult medical-surgical ICU patients, in-hospital substantial acute stress symptoms were associated with a greater risk of rehospitalization within 1 year post-ICU discharge; those with substantial post traumatic stress disorder symptoms at 3 months post-ICU also had a greater risk of future emergency department visits within the year.
SOURCE: Davydow DS, et al. Psychiatric symptoms and acute care service utilization over the course of the year following medical-surgical ICU admission: A longitudinal investigation. Crit Care Med 2014;42:2473-2481.
Over the past two decades, advances in critical care have resulted in more patients surviving to hospital discharge, but these successes are attenuated by several sequelae of critical illness, including depression and post-traumatic stress disorder (PTSD).1 Risk factors for and the health care ramifications of these disorders are poorly understood. Given this, Davydow and colleagues aimed to investigate whether PTSD symptoms in the acute (< 1 month) ICU hospitalization period and PTSD and depressive symptoms at 3 months post-ICU were risk factors for future hospitalizations and emergency department (ED) visits.
Over a 12-month period (2010-2011) at Harborview Medical Center (Seattle, WA), 150 adult patients admitted to medical-surgical ICUs were prospectively recruited. The primary exposure variables were the presence of acute stress symptoms, as assessed by the PTSD Checklist-Civilian version (PCL-C) prior to hospital discharge and at 3 months post-ICU, and depressive symptoms at 3 months post-ICU, as ascertained by the Patient Health Questionnaire-9 (PHQ-9).2,3 Substantial acute stress symptoms were defined as scoring > 3 on at least one intrusive symptom, three avoidant symptoms, and two arousal symptoms on the PCL-C; substantial depressive symptoms were defined as a PHQ-9 score of > 10.
Baseline interviews were conducted a median of 8 days (IQR 5–15) after hospital admission. Primary outcomes were number of hospitalizations and ED visits between discharge and 12 months post-ICU. Over the past two decades, advances in critical care have resulted in more patients surviving to hospital discharge, but these successes are attenuated by several sequelae of critical illness, including depression and post-traumatic stress disorder (PTSD).1 Risk factors for and the health care ramifications of these disorders are poorly understood. Given this, Davydow and colleagues aimed to investigate whether PTSD symptoms in the acute (< 1 month) ICU hospitalization period and PTSD and depressive symptoms at 3 months post-ICU were risk factors for future hospitalizations and emergency department (ED) visits.
After adjustment for baseline patient-related (including history of major depression, alcohol/drug use, Charlson comorbidity score among other variables) and hospitalization-related (including mechanical ventilation duration, admission diagnosis, number of surgeries) characteristics, substantial PTSD symptoms in the hospital were associated with a greater risk of rehospitalizations within 1 year of ICU discharge (relative risk [RR], 3.00; 95% confidence interval [CI], 1.80-4.99); there was also a non-significant trend toward increased risk of future ED visits (RR, 1.94; 95% CI, 0.95-3.98). In addition, substantial PTSD symptoms at 3-months post-ICU were associated with a greater risk of ED visits within the year after ICU discharge (RR, 2.29; 95% CI, 1.09-4.84), even after additional adjustment for acute care service utilization in the 3 months post-ICU discharge. Depressive symptoms at 3 month follow-up were not associated with risk of rehospitalization or additional ED visits between 3 and 12 months post-ICU.
This study adds to the growing body of literature describing the post-discharge needs of ICU survivors as substantial. Inarguably, critical care interventions, such as low tidal volume ventilation for acute respiratory distress syndrome and early antibiotics and fluid resuscitation in sepsis, have saved lives. However, in the same way that heart disease and cancer have replaced infection as the leading causes of death, our achievements are tempered by the generation of a growing population of patients with chronic medical problems as a result of their critical illness: psychiatric disorders, profound neuromuscular weakness, endocrinopathy, malnutrition, increased vulnerability to infection, functional disability, and symptom distress. This study highlights the need for focused attention, follow-up, interventions, and research in the post-ICU period. These efforts should not only help individual patients manage their symptoms and comorbidities, but would hopefully have beneficial effects on both preventing further disability and complications, as well as reducing health care costs through decreasing rates of utilization of acute care services such as recurrent hospitalizations and ED visits.
1. Zimmerman JE, et al. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. Crit Care 2013;17:R81.
2. Weathers FW, et al. The PTSD Checklist-Civilian Version. Boston, MA, The National Center for PTSD, Boston VA Medical Center, 1991.
3. Kroenke K, et al. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-613.