Browsing by Person "Walsh, Timothy S."

Now showing 1 - 13 of 13

A rehabilitation intervention to promote physical recovery following intensive care: a detailed description of construct development, rationale and content together with proposed taxonomy to capture processes in a randomised controlled trial
(2014-01-29) Ramsay, Pamela; Salisbury, Lisa; Merriweather, Judith L.; Huby, G.; Rattray, Janice; Hull, Alastair M.; Brett, Stephen J.; Mackenzie, Simon J.; Murray, Gordon D.; Forbes, John F.; Walsh, Timothy S.
Increasing numbers of patients are surviving critical illness, but survival may be associated with a constellation of physical and psychological sequelae that can cause ongoing disability and reduced health-related quality of life. Limited evidence currently exists to guide the optimum structure, timing, and content of rehabilitation programmes. There is a need to both develop and evaluate interventions to support and expedite recovery during the post-ICU discharge period. This paper describes the construct development for a complex rehabilitation intervention intended to promote physical recovery following critical illness. The intervention is currently being evaluated in a randomised trial (ISRCTN09412438; funder Chief Scientists Office, Scotland). Methods The intervention was developed using the Medical Research Council (MRC) framework for developing complex healthcare interventions. We ensured representation from a wide variety of stakeholders including content experts from multiple specialties, methodologists, and patient representation. The intervention construct was initially based on literature review, local observational and audit work, qualitative studies with ICU survivors, and brainstorming activities. Iterative refinement was aided by the publication of a National Institute for Health and Care Excellence guideline (No. 83), publicly available patient stories (Healthtalkonline), a stakeholder event in collaboration with the James Lind Alliance, and local piloting. Modelling and further work involved a feasibility trial and development of a novel generic rehabilitation assistant (GRA) role. Several rounds of external peer review during successive funding applications also contributed to development.
Determinants of Health-Related Quality of Life After ICU: Importance of Patient Demographics, Previous Comorbidity, and Severity of Illness.
(2018-04-01) Griffith, David M.; Salisbury, Lisa; Lee, Robert J.; Lone, Nazir; Merriweather, Judith L.; Walsh, Timothy S.
ICU survivors frequently report reduced health-related quality of life, but the relative importance of preillness versus acute illness factors in survivor populations is not well understood. We aimed to explore health-related quality of life trajectories over 12 months following ICU discharge, patterns of improvement, or deterioration over this period, and the relative importance of demographics (age, gender, social deprivation), preexisting health (Functional Comorbidity Index), and acute illness severity (Acute Physiology and Chronic Health Evaluation II score, ventilation days) as determinants of health-related quality of life and relevant patient-reported symptoms during the year following ICU discharge. Nested cohort study within a previously published randomized controlled trial. Two ICUs in Edinburgh, Scotland. Adult ICU survivors (n = 240) who required more than 48 hours of mechanical ventilation. None. We prospectively collected data for age, gender, social deprivation (Scottish index of multiple deprivation), preexisting comorbidity (Functional Comorbidity Index), Acute Physiology and Chronic Health Evaluation II score, and days of mechanical ventilation. Health-related quality of life (Medical Outcomes Study Short Form version 2 Physical Component Score and Mental Component Score) and patient-reported symptoms (appetite, fatigue, pain, joint stiffness, and breathlessness) were measured at 3, 6, and 12 months. Mean Physical Component Score and Mental Component Score were reduced at all time points with minimal change between 3 and 12 months. In multivariable analysis, increasing pre-ICU comorbidity count was strongly associated with lower health-related quality of life (Physical Component Score _ = -1.56 [-2.44 to -0.68]; p = 0.001; Mental Component Score _ = -1.45 [-2.37 to -0.53]; p = 0.002) and more severe self-reported symptoms. In contrast, Acute Physiology and Chronic Health Evaluation II score and mechanical ventilation days were not associated with health-related quality of life. Older age (_ = 0.33 [0.19-0.47]; p < 0.001) and lower social deprivation (_ = 1.38 [0.03-2.74]; p = 0.045) were associated with better Mental Component Score health-related quality of life. Preexisting comorbidity counts, but not severity of ICU illness, are strongly associated with health-related quality of life and physical symptoms in the year following critical illness.
Exercise rehabilitation following intensive care unit discharge for recovery from critical illness
(2015-06-22) Connolly, Bronwen; Salisbury, Lisa; O'Neill, Brenda; Geneen, Louise; Douiri, Abdel; Grocott, Michael PW; Hart, Nicholas; Walsh, Timothy S.; Blackwood, Bronagh
Background Skeletal muscle wasting and weakness are significant complications of critical illness, associated with degree of illness severity and periods of reduced mobility during mechanical ventilation. They contribute to the profound physical and functional deficits observed in survivors. These impairments may persist for many years following discharge from the intensive care unit (ICU) and can markedly influence health-related quality of life. Rehabilitation is a key strategy in the recovery of patients after critical illness. Exercise-based interventions are aimed at targeting this muscle wasting and weakness. Physical rehabilitation delivered during ICU admission has been systematically evaluated and shown to be beneficial. However, its effectiveness when initiated after ICU discharge has yet to be established. Objectives To assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, for functional exercise capacity and health-related quality of life in adult ICU survivors who have been mechanically ventilated longer than 24 hours
Exercise rehabilitation following intensive care unit discharge for recovery from critical illness: executive summary of a Cochrane Collaboration systematic review
(2016-09-16) Connolly, Bronwen; Salisbury, Lisa; O'Neill, Brenda; Geneen, Louise; Douiri, Abdel; Grocott, Michael PW; Hart, Nicholas; Walsh, Timothy S.; Blackwood, Bronagh
Skeletal muscle wasting and weakness are major complications of critical illness and underlie the profound physical and func- tional impairments experienced by survivors after discharge from the intensive care unit (ICU). Exercise-based rehabilitation has been shown to be bene fi cial when delivered during ICU admission. This review aimed to determine the effectiveness of exercise rehabilitation initiated after ICU discharge on primary outcomes of functional exercise capacity and health-related quality of life. We sought randomized controlled trials, quasi-randomized controlled trials, and controlled clinical trials compar- ing an exercise intervention commenced after ICU discharge vs. any other intervention or a control or ' usual care ' programme in adult survivors of critical illness. Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval Sys- tem Online (MEDLINE), Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature databases were searched up to February 2015. Dual, independent screening of results, data extraction, and quality appraisal were per- formed. We included six trials involving 483 patients. Overall quality of evidence for both outcomes was very low. All studies evaluated functional exercise capacity, with three reporting positive effects in favour of the intervention. Only two studies evaluated health-related quality of life and neither reported differences between intervention and control groups. Meta- analyses of data were precluded due to variation in study design, types of interventions, and selection and reporting of out- come measurements. We were unable to determine an overall effect on functional exercise capacity or health-related quality of life of interventions initiated after ICU discharge for survivors of critical illness. Findings from ongoing studies are awaited. Future studies need to address methodological aspects of study design and conduct to enhance rigour, quality, and synthesis.
Exercise rehabilitation for recovery from critical illness (Protocol)
(The Cochrane Collaboration, 2010) Geneen, Louise; Mercer, Tom; Salisbury, Lisa; Walsh, Timothy S.; Thomson, Colin E.
This is the protocol for a review and there is no abstract. The objectives are as follows: The objective of this systematic review is to assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, on improving functional exercise capacity and quality of life in adult ICU survivors who have been mechanically ventilated for more than 24 hours. We will compare an exercise intervention to any other intervention or a control or 'usual care' programme. Exercise includes any structured or taught programmes. Respiratory or inspiratory muscle training is excluded due to it being initiated within the ICU environment, for example with weaning from a ventilator, and not as post-discharge rehabilitation as required for this review.
Increased Hospital-Based Physical Rehabilitation and Information Provision After Intensive Care Unit Discharge
(2015-04-13) Walsh, Timothy S.; Salisbury, Lisa; Merriweather, Judith L.; Boyd, Julia A.; Griffith, David M.; Huby, G.; Kean, Susanne; Mackenzie, Simon J.; Krishan, Ashma; Lewis, Stephanie C.; Murray, Gordon D.; Forbes, John F.; Smith, Joel; Rattray, Janice; Hull, Alastair M.; Ramsay, Pamela
Importance Critical illness results in disability and reduced health-related quality of life (HRQOL), but the optimum timing and components of rehabilitation are uncertain. Objective To evaluate the effect of increasing physical and nutritional rehabilitation plus information delivered during the post-intensive care unit (ICU) acute hospital stay by dedicated rehabilitation assistants on subsequent mobility, HRQOL, and prevalent disabilities. Design, Setting, and Participants A parallel group, randomized clinical trial with blinded outcome assessment at 2 hospitals in Edinburgh, Scotland, of 240 patients discharged from the ICU between December 1, 2010, and January 31, 2013, who required at least 48 hours of mechanical ventilation. Analysis for the primary outcome and other 3-month outcomes was performed between June and August 2013; for the 6- and 12-month outcomes and the health economic evaluation, between March and April 2014. Interventions During the post-ICU hospital stay, both groups received physiotherapy and dietetic, occupational, and speech/language therapy, but patients in the intervention group received rehabilitation that typically increased the frequency of mobility and exercise therapies 2- to 3-fold, increased dietetic assessment and treatment, used individualized goal setting, and provided greater illness-specific information. Intervention group therapy was coordinated and delivered by a dedicated rehabilitation practitioner. Main Outcomes and Measures The Rivermead Mobility Index (RMI) (range 0-15) at 3 months; higher scores indicate greater mobility. Secondary outcomes included HRQOL, psychological outcomes, self-reported symptoms, patient experience, and cost-effectiveness during a 12-month follow-up (completed in February 2014). Results Median RMI at randomization was 3 (interquartile range [IQR], 1-6) and at 3 months was 13 (IQR, 10-14) for the intervention and usual care groups (mean difference, -0.2 [95% CI, -1.3 to 0.9; P-=-.71]). The HRQOL scores were unchanged by the intervention (mean difference in the Physical Component Summary score, -0.1 [95% CI, -3.3 to 3.1; P-=-.96]; and in the Mental Component Summary score, 0.2 [95% CI, -3.4 to 3.8; P-=-.91]). No differences were found for self-reported symptoms of fatigue, pain, appetite, joint stiffness, or breathlessness. Levels of anxiety, depression, and posttraumatic stress were similar, as were hand grip strength and the timed Up & Go test. No differences were found at the 6- or 12-month follow-up for any outcome measures. However, patients in the intervention group reported greater satisfaction with physiotherapy, nutritional support, coordination of care, and information provision. Conclusions and Relevance Post-ICU hospital-based rehabilitation, including increased physical and nutritional therapy plus information provision, did not improve physical recovery or HRQOL, but improved patient satisfaction with many aspects of recovery.
"Intensive care unit survivorship" - a constructivist grounded theory of surviving critical illness
(2017-10-30) Kean, Susanne; Salisbury, Lisa; Rattray, Janice; Walsh, Timothy S.; Huby, G.; Ramsay, Pamela
Aims and objectives To theorise intensive care unit survivorship after a critical illness based on longitudinal qualitative data. Background Increasingly, patients survive episodes of critical illness. However, the short- and long-term impact of critical illness includes physical, psychological, social and economic challenges long after hospital discharge. An appreciation is emerging that care needs to extend beyond critical illness to enable patients to reclaim their lives postdischarge with the term 'survivorship' being increasingly used in this context. What constitutes critical illness survivorship has, to date, not been theoretically explored.
Nutritional care after critical illness: a qualitative study of patients' experiences
(2014-12-18) Merriweather, Judith L.; Salisbury, Lisa; Walsh, Timothy S.; Smith, Pam
Background The present qualitative study aimed to explore the factors influencing nutritional recovery in patients after critical illness and to develop a model of care to improve current management of nutrition for this patient group. Methods Patients were recruited into the study on discharge from a general intensive care unit (ICU) of a large teaching hospital in central Scotland. Semi-structured interviews were carried out after discharge from the ICU, weekly for the duration of their ward stay, and at 3 months post ICU discharge. Observations of ward practice were undertaken thrice weekly for the duration of the ward stay. Results Seventeen patients were recruited into the study and, using a grounded theory approach, 'inter-related system breakdowns during the nutritional recovery process' emerged as the overarching core category that influenced patients' experiences of eating after critical illness. This encompassed the categories, 'experiencing a dysfunctional body', 'experiencing socio-cultural changes in relation to eating' and 'encountering nutritional care delivery failures'. Conclusions The findings from the present study provide a unique contribution to knowledge by offering important insights into patients' experiences of eating after critical illness. The study has identified numerous nutritional problems and raises questions about the efficacy of current nutritional management in this patient group. Adopting a more individualised approach to nutritional care could ameliorate the nutritional issues experienced by post ICU patients. This will be evaluated in future work.
Patient and carer experience of hospital-based rehabilitation from intensive care to hospital discharge: mixed methods process evaluation of the RECOVER randomised clinical trial
(2016-08-01) Ramsay, Pamela; Huby, G.; Merriweather, Judith L.; Salisbury, Lisa; Rattray, Janice; Griffith, David M.; Walsh, Timothy S.
Objectives: To explore and compare patient/carer experiences of rehabilitation in the intervention and usual care arms of the RECOVER trial (ISRCTN09412438); a randomised controlled trial of a complex intervention of post-intensive care unit (ICU) acute hospital-based rehabilitation following critical illness. Design: Mixed methods process evaluation including comparison of patients' and carers' experience of usual care versus the complex intervention. We integrated and compared quantitative data from a patient experience questionnaire (PEQ) with qualitative data from focus groups with patients and carers. Setting: Two university-affiliated hospitals in Scotland.
Predicting risk of unplanned hospital readmission in survivors of critical illness: A population-level cohort study
(2018-04-06) Lone, Nazir; Lee, Robert J.; Salisbury, Lisa; Donaghy, Eddie; Ramsay, Pamela; Rattray, Janice; Walsh, Timothy S.
Background Intensive care unit (ICU) survivors experience high levels of morbidity after hospital discharge and are at high risk of unplanned hospital readmission. Identifying those at highest risk before hospital discharge may allow targeting of novel risk reduction strategies. We aimed to identify risk factors for unplanned 90-day readmission, develop a risk prediction model and assess its performance to screen for ICU survivors at highest readmission risk. Methods Population cohort study linking registry data for patients discharged from general ICUs in Scotland (2005-2013). Independent risk factors for 90-day readmission and discriminant ability (c-index) of groups of variables were identified using multivariable logistic regression. Derivation and validation risk prediction models were constructed using a time-based split. Results Of 55 975 ICU survivors, 24.1% (95%CI 23.7% to 24.4%) had unplanned 90-day readmission. Pre-existing health factors were fair discriminators of readmission (c-index 0.63, 95%-CI 0.63 to 0.64) but better than acute illness factors (0.60) or demographics (0.54). In a subgroup of those with no comorbidity, acute illness factors (0.62) were better discriminators than pre-existing health factors (0.56). Overall model performance and calibration in the validation cohort was fair (0.65, 95%-CI 0.64 to 0.66) but did not perform sufficiently well as a screening tool, demonstrating high false-positive/false-negative rates at clinically relevant thresholds. Conclusions Unplanned 90-day hospital readmission is common. Pre-existing illness indices are better predictors of readmission than acute illness factors. Identifying additional patient-centred drivers of readmission may improve risk prediction models. Improved understanding of risk factors that are amenable to intervention could improve the clinical and cost-effectiveness of post-ICU care and rehabilitation.
PReventing early unplanned hOspital readmission aFter critical ILlnEss (PROFILE): protocol and analysis framework for a mixed methods study
(2016-06-28) Walsh, Timothy S.; Salisbury, Lisa; Donaghy, Eddie; Ramsay, Pamela; Lee, Robert J.; Rattray, Janice; Lone, Nazir
Introduction: Survivors of critical illness experience multidimensional disabilities that reduce quality of life, and 25-30% require unplanned hospital readmission within 3 months following index hospitalisation. We aim to understand factors associated with unplanned readmission; develop a risk model to identify intensive care unit (ICU) survivors at highest readmission risk; understand the modifiable and non-modifiable readmission drivers; and develop a risk assessment tool for identifying patients and areas for early intervention. Methods and analysis: We will use mixed methods with concurrent data collection. Quantitative data will comprise linked healthcare records for adult Scottish residents requiring ICU admission (1 January 2000-31 December 2013) who survived to hospital discharge. The outcome will be unplanned emergency readmission within 90 days of index hospital discharge. Exposures will include pre-ICU demographic data, comorbidities and health status, and critical illness variables representing illness severity. Regression analyses will be used to identify factors associated with increased readmission risk, and to develop and validate a risk prediction model. Qualitative data will comprise recorded/transcribed interviews with up to 60 patients and carers recently experiencing unplanned readmissions in three health board regions. A deductive and inductive thematic analysis will be used to identify factors contributing to readmissions and how they may interact. Through iterative triangulation of quantitative and qualitative data, we will develop a construct/ taxonomy that captures reasons and drivers for unplanned readmission. We will validate and further refine this in focus groups with patients/carers who experienced readmissions in six Scottish health board regions, and in consultation with an independent expert group. A tool will be developed to screen for ICU survivors at risk of readmission and inform anticipatory interventions.
Systemic inflammation after critical illness: relationship with physical recovery and exploration of potential mechanisms
(2016-08-12) Griffith, David M.; Lewis, Steff; Rossi, Adriano G.; Rennie, Jillian; Salisbury, Lisa; Merriweather, Judith L.; Templeton, Kate; Walsh, Timothy S.
Background Physical recovery following critical illness is slow, often incomplete and is resistant to rehabilitation interventions. We aimed to explore the contribution of persisting inflammation to recovery, and investigated the potential role of human cytomegalovirus (HCMV) infection in its pathogenesis. Methods In an a priori nested inflammatory biomarker study in a post-intensive care unit (ICU) rehabilitation trial (RECOVER; ISRCTN09412438), surviving adult ICU patients ventilated >48-h were enrolled at ICU discharge and blood sampled at ICU discharge (n=184) and 3-month follow-up (N=123). C-reactive protein (CRP), human neutrophil elastase (HNE), interleukin (IL)-1_, IL-6, IL-8, transforming growth factor _1 (TGF_1) and secretory leucocyte protease inhibitor (SLPI) were measured. HCMV IgG status was determined (previous exposure), and DNA PCR measured among seropositive patients (lytic infection). Physical outcome measures including the Rivermead Mobility Index (RMI) were measured at 3-months. Results Many patients had persisting inflammation at 3-months (CRP >3-mg/L in 59%; >10-mg/L in 28%), with proinflammatory phenotype (elevated HNE, IL-6, IL-8, SLPI; low TGF_1). Poorer mobility (RMI) was associated with higher CRP (_=0.13; p<0.01) and HNE (_=0.32; p=0.03), even after adjustment for severity of acute illness and pre-existing co-morbidity (CRP _=0.14; p<0.01; HNE _=0.30; p=0.04). Patients seropositive for HCMV at ICU discharge (63%) had a more proinflammatory phenotype at 3-months than seronegative patients, despite undetectable HMCV by PCR testing. Conclusions Inflammation is prevalent after critical illness and is associated with poor physical recovery during the first 3-months post-ICU discharge. Previous HCMV exposure is associated with a proinflammatory phenotype despite the absence of detectable systemic viraemia. Trial registration number ISRCTN09412438, post results.
The Burden of Specific Symptoms Reported by Survivors after Critical Illness
(2018-01-15) Griffith, David M.; Salisbury, Lisa; Lee, Robert J.; Lone, Nazir; Merriweather, Judith L.; Walsh, Timothy S.