Background Critical illness is associated with cognitive impairment, but mental health and functional disabilities in general intensive care unit (ICU) survivors are inadequately characterized and there are a paucity of data regarding the relationship between age and delirium and these outcomes. Methods In this prospective, multisite cohort study, we enrolled medical/surgical ICU patients with respiratory failure or shock, collected detailed demographics and in-hospital variables, and assessed survivors at 3 and 12 months with measures of depression, posttraumatic stress disorder (PTSD) and functional disability. We used linear and proportional odds logistic regression to examine the independent associations between age and delirium duration versus mental health and functional disabilities. Findings We enrolled 821 patients with a median (interquartile range) age of 61 (51, 71), assessing 448 patients and 382 patients 3 and 12 months after discharge. At 3- and 12-month follow-up, 37% (149/407) and 33% (116/347) of subjects reported at least mild depression, driven primarily by somatic rather than cognitive symptoms. Depressive symptoms were common even among those with no proxy reported history of depression, reported at 3- and 12-month follow-up by 30% (76/255) and 29% (62/217) of these individuals. At either follow-up assessment, only 7% (27/415, 24/361) of subjects had symptoms consistent with PTSD. Disabilities in basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs) were present in 32% (139/428) and 26% (108/422) of individuals at 3 months and in 27% (102/374) and 23%(87/372) at 12 months. Mental health and functional difficulties were prevalent in young and old patients. Although older age was frequently associated with mental health and functional disabilities, no consistent association was observed between delirium and these outcomes. Interpretation In contrast with early single-center reports, data from this large, multicenter investigation reveal depression is much more common than PTSD after critical illness and is driven by somatic symptoms indicative of physical disabilities rather than by cognitive symptoms. Poor mental health and functional disability were common, and persistent in up to a quarter of patients.

Objective The debilitating and persistent effects of intensive care unit (ICU)-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle into everyday practice. Design Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012. Setting Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center. Patients Two hundred ninety-six patients (146 pre- and 150 post-bundle implementation), age ≥ 19 years, managed by the institutions’ medical or surgical critical care service. Interventions ABCDE bundle. Measurements For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between ABCDE bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Main Results Patients in the post-implementation period spent three more days breathing without mechanical assistance than did those in the pre-implementation period (median [IQR], 24 [7 to 26] vs. 21 [0 to 25]; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the ABCDE bundle experienced a near halving of the odds of delirium (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.33–0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (OR, 2.11; 95% CI, 1.29–3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates. Conclusions Critically ill patients managed with the ABCDE bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.

New financial penalties for institutions with high readmission rates have intensified efforts to reduce rehospitalization. Several interventions that involve multiple components (e.g., patient needs assessment, medication reconciliation, patient education, arranging timely outpatient appointments, and providing telephone follow-up), have successfully reduced readmission rates for patients discharged to home. The effect of interventions on readmission rates is related to the number of components implemented, whereas single-component interventions are unlikely to reduce readmissions significantly. For patients discharged to post-acute care facilities, multicomponent interventions have reduced readmissions through enhanced communication, medication safety, advanced care planning, and enhanced training to manage common medical conditions that commonly precipitate readmission. To help hospitals direct resources and services to patients with greater likelihood of readmission, a number of risk stratification methods are available. Future work should better define the role of home-based services, information technology, mental health care, caregiver support, community partnerships, and new transitional care personnel.