Surviving intensive care
KeywordsIntensive Care Medicine Physiotherapy Intervention Triage Decision Rehabilitation Care Iatrogenic Complication
intensive care unit.
Until 15 years ago the speciality of intensive care concentrated on immediate consequences, including death, and if the patient left the ICU there was little in the literature regarding the long-term sequelae. A Kings Fund Report at about that time stated that 'there is more to life than measuring death', and indeed a successful outcome was not just about 'surviving intensive care' but about getting out of hospital and returning home to a good quality of life. The idea of following up patients after ICU treatment was not something most intensivists embraced but remained the preserve of a few enthusiasts in the UK, although it is now becoming more widespread since the Audit Commission (Critical to Success) and the National Health Service Executive (Comprehensive Critical Care) published their documents during the past 4 years.
It is heartening for me to see a book on the subject edited by two eminent intensivists, one from France and the other from the USA (although originally Scottish). The book includes 25 chapters written by 48 well known authors. The editors managed to group the chapters into broad subsections. There is no cross-referencing between chapters.
I liked the mention in Chapter 1 of the appropriateness of the ICU for HIV patients in the light of new treatment regimes that have radically altered long-term outcome, and in the chapter on neuropsychological consequences of intensive care the word 'skepticism' was used (page 51) referring to any multicentre trial published without long-term data which for me fully justifies the need for following up patients after they have left the intensive care environment.
Trying to put a monetary value on the long-term consequences of surviving intensive care was the theme of Chapter 6 and is essential reading. It is my experience, however, that many patients do not receive appropriate rehabilitation care (unlike post-myocardial infarction patients), including the most basic physiotherapy interventions, once they are back in the community; this can further complicate the equation. The second subsection of the book concentrates on predictors/modifiers of long-term outcomes, and the main point that surfaces is the lack of data.
There is no doubt that we need to improve the methods by which we capture long-term ICU survival data. This is the subject of the third subsection of the book, and the point is well made that we should look to cancer research, in which a successful multidisciplinary approach has been used for 50 years, for clues to guide us in the follow up of ICU patients. The chapter in which information provided to family members is evaluated is interesting and extremely important, but it did not necessarily fit into this book.
In the last subsection of the book the need to be more proactive in modifying triage decisions to optimize triage decisions was discussed, and I was particularly glad to see one of the recommendations, namely that 'appropriate areas outside ICU should be developed for the care of terminal patients and patients requiring monitoring and not ICU care.'
The two chapters that I found the most useful were those on preventing iatrogenic complications and on the re-organising health care systems to optimise critical care outcome. If we need to improve outcomes, then we need to reduce the high incidence of medical error both within and outside ICUs; in order to achieve this, we must embrace health informatics.
Overall this is an excellent collection of papers with something for everybody involved in intensive care medicine, but I was a touch disappointed by the fact that none of the authors were nurses and that reference to ICU follow-up clinics, of which there are several well-developed ones in the UK, was minimal. I was very disappointed that the opportunity to ask a patient to contribute an account of their experience in an ICU was not grasped; maybe next time!
- 1.Angus DC, Carlet J: Surviving Intensive Care. Update in Intensive Care and Emergency Medicine 39. 2003, Berlin. Springer-Verlag, 344-ISBN 3-540-43811-4 (Hbk)Google Scholar