Nathaniel E. Brummel

Objectives: Interhospital transfer is essential for accessing specialized critical care services, yet it poses clinical risk and substantial burden for patients and the healthcare system. Tele-critical care (TCC) programs extend expertise to resource-limited hospitals and may influence transfer decisions by identifying patients requiring escalation or supporting local management. We examined the association between TCC capability at index ICU hospitalizations, interhospital transfer, and post-transfer outcomes. Design: Nationwide retrospective cohort study using 2021–2023 Medicare claims linked to the American Hospital Association Annual Survey Database (AHAASD). Setting: U.S. acute care hospitals. Patients: Medicare fee-for-service beneficiaries with ICU hospitalizations between 2022 and 2023. Interventions: None. Measurements and Main Results: TCC capability was identified by AHAASD reporting and/or the presence of five or more TCC claims annually. The primary outcome was interhospital ICU transfer. Exploratory post-transfer outcomes included receipt of specialty procedures, death or hospice discharge within 1 day of transfer, in-hospital and 30-day mortality, and discharge disposition. Hierarchical logistic regression adjusted for patient demographics, comorbidities, acute organ failures, and transferring/accepting hospital characteristics, with transferring hospitals as random intercepts. Among 2,140,919 ICU hospitalizations, 33.4% occurred at 1,066 TCC-capable hospitals. Absolute transfer rates were similar (2.5% vs. 3.0%), but TCC capability was associated with higher adjusted odds of transfer (adjusted odds ratio [aOR], 1.08; 95% CI, 1.01–1.14). In exploratory post-transfer analyses, transferred patients from TCC hospitals had greater illness severity yet were less likely to die or be discharged to hospice within 1 day of transfer (4.6% vs. 6.6%; aOR, 0.86; 95% CI, 0.76–0.97) and more likely to be discharged home within 2 days (4.7% vs. 3.7%; aOR, 1.17; 95% CI, 1.03–1.33). Conclusions: TCC capability was associated with modestly increased transfer rates, fewer potentially low-value transfers, and improved post-transfer outcomes, suggesting improved transfer selection.

There is limited information on the relationship between multidisciplinary bundle compliance and long-term outcomes. We explored the association between bundle compliance and outcomes at 3 and 12 months after hospital discharge. We conducted secondary analyses of a randomized controlled trial comparing haloperidol, ziprasidone, and placebo for delirium in patients with critical illness. From 2011 to 2017, adult patients with respiratory failure and/or shock were recruited from 16 US medical centers. Participants received a daily ABCDE bundle during their critical illness. We assessed cognition, disability, mental health, quality of life, and survival over 12 months of follow-up. We analyzed data using linear mixed effects regression and Cox proportional hazards models. Among 566 participants, 418 survived to hospital discharge, 304 were assessed for 3-month outcomes, and 251 for 12-month outcomes. Median proportional bundle compliance was 97%, indicating high overall fidelity. After adjusting for covariates, greater proportional bundle compliance was associated with better functional independence and health-related quality of life, as evidenced by lower 12-month Functional Activity Questionnaire scores (β = - 9.6, CI = - 19.6, - 1.7, p = 0.04) and higher 12-month EuroQol-5D scores (β = 0.5, CI = 0.1, 0.9, p = 0.01). Greater bundle compliance was not associated with better long-term cognition, mental health, or survival. In this multi-site cohort with high-fidelity bundle compliance, greater bundle compliance was associated with less disability in instrumental activities of daily living and better health-related quality of life at 12 months, though associations were inconsistent and absent across other domains. Future research should evaluate integrated bundle care with post-discharge interventions to optimize long-term recovery. The Modifying the Impact of ICU-Associated Neurological Dysfunction-USA Study (MIND-USA), NCT01211522, https://clinicaltrials.gov/ct2/show/NCT01211522 .

During critical illness, patients experience significant and rapid onsets of muscle wasting and dysfunction with loss of strength, mass, and power. These deficits often persist long after the ICU, leading to impairments in physical function including reduced exercise capacity and increased frailty and disability. While there are numerous studies describing the epidemiology of impaired muscle and physical function in the ICU, there are significantly fewer data investigating mechanisms of prolonged and persistent impairments in ICU survivors. Additionally, while several potential clinical risk factors associated with poor physical recovery have been identified, there remains a dearth of interventions that have effectively improved outcomes long-term among survivors. In this article, we aim to provide a thorough, evidence-based review of the current state of knowledge regarding muscle dysfunction and physical function after critical illness with a focus on post-ICU and post-hospitalization phase of recovery.

OBJECTIVES: Sepsis survivors have greater healthcare use than those surviving hospitalizations for other reasons, yet factors associated with greater healthcare use in this population remain ill-defined. Rural Americans are older, have more chronic illnesses, and face unique barriers to healthcare access, which could affect postsepsis healthcare use. Therefore, we compared healthcare use and expenditures among rural and urban sepsis survivors. We hypothesized that rural survivors would have greater healthcare use and expenditures. DESIGN, SETTING, AND PATIENTS: To test this hypothesis, we used data from 106,189 adult survivors of a sepsis hospitalization included in the IBM MarketScan Commercial Claims and Encounters database and Medicare Supplemental database between 2013 and 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified hospitalizations for severe sepsis and septic shock using the International Classification of Diseases, 9th Edition (ICD-9) or 1CD-10 codes. We used Metropolitan Statistical Area classifications to categorize rurality. We measured emergency department (ED) visits, inpatient hospitalizations, skilled nursing facility admissions, primary care visits, physical therapy visits, occupational therapy visits, and home healthcare visits for the year following sepsis hospitalizations. We calculated the total expenditures for each of these categories. We compared outcomes between rural and urban patients using multivariable regression and adjusted for covariates. After adjusting for age, sex, comorbidities, admission type, insurance type, U.S. Census Bureau region, employment status, and sepsis severity, those living in rural areas had 17% greater odds of having an ED visit (odds ratio [OR] 1.17; 95% CI, 1.13–1.22; p < 0.001), 9% lower odds of having a primary care visit (OR 0.91; 95% CI, 0.87–0.94; p < 0.001), and 12% lower odds of receiving home healthcare (OR 0.88; 95% CI, 0.84–0.93; p < 0.001). Despite higher levels of ED use and equivalent levels of hospital readmissions, expenditures in these areas were 14% (OR 0.86; 95% CI, 0.80–0.91; p < 0.001) and 9% (OR 0.91; 95% CI, 0.87–0.96; p < 0.001) lower among rural survivors, respectively, suggesting these services may be used for lower-acuity conditions. CONCLUSIONS: In this large cohort study, we report important differences in healthcare use and expenditures between rural and urban sepsis survivors. Future research and policy work is needed to understand how best to optimize sepsis survivorship across the urban-rural continuum.

Purpose The purpose of this study was to determine associations between markers of inflammation and endogenous anticoagulant activity with delirium and coma during critical illness. Methods In this prospective cohort study, we enrolled adults with respiratory failure and/or shock treated in medical or surgical intensive care units (ICUs) at 5 centers. Twice per day in the ICU, and daily thereafter, we assessed mental status using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method-Intensive Care Unit (CAM-ICU). We collected blood samples on study days 1, 3, and 5, measuring levels of C-reactive protein (CRP), interferon gamma (IFN-γ), interleukin (IL)-1 beta (IL-1β), IL-6, IL-8, IL-10, IL-12, matrix metalloproteinase-9 (MMP-9), tumor necrosis factor-alpha (TNF-α), tumor necrosis factor receptor 1 (TNFR1), and protein C using validated protocols. We used multinomial logistic regression to analyze associations between biomarkers and the odds of delirium or coma versus normal mental status the following day, adjusting for age, sepsis, Sequential Organ Failure Assessment (SOFA), study day, corticosteroids, and sedatives. Results Among 991 participants with a median age (interquartile range, IQR) of 62 [53–72] years and enrollment SOFA of 9 [7–11], higher concentrations of IL-6 (odds ratio [OR] [95% CI]: 1.8 [1.4–2.3]), IL-8 (1.3 [1.1–1.5]), IL-10 (1.5 [1.2–1.8]), TNF-α (1.2 [1.0–1.4]), and TNFR1 (1.3 [1.1–1.6]) and lower concentrations of protein C (0.7 [0.6–0.8])) were associated with delirium the following day. Higher concentrations of CRP (1.4 [1.1–1.7]), IFN-γ (1.3 [1.1–1.5]), IL-6 (2.3 [1.8–3.0]), IL-8 (1.8 [1.4–2.3]), and IL-10 (1.5 [1.2–2.0]) and lower concentrations of protein C (0.6 [0.5–0.8]) were associated with coma the following day. IL-1β, IL-12, and MMP-9 were not associated with mental status. Conclusion Markers of inflammation and possibly endogenous anticoagulant activity are associated with delirium and coma during critical illness.

Hospital delirium is a dangerous condition characterized by confusion and altered consciousness. Delirium is frequently missed or not recognized by hospital teams. Hypoactive delirium, the most common type of delirium in hospitals, is associated with decreased spontaneous movements. We evaluated the use of wrist accelerometers to detect an association with delirium in hospitalized patients. We found that daily mean activity count was lower in patients with delirium, even controlling for age and mechanical ventilation status. This suggests that accelerometers could be a good biosensor to assist hospital staff with delirium detection and management.

People with respiratory disease have increased risk of developing frailty, which is associated with worse health outcomes. There is growing evidence of the role of rehabilitation in managing frailty in people with respiratory disease. However, several challenges remain regarding optimal methods of identifying frailty and delivering rehabilitation for this population. The aims of this American Thoracic Society workshop were to outline key definitions and concepts around rehabilitation for people with respiratory disease and frailty, synthesize available evidence, and explore how programs may be adapted to align to the needs and experiences of this population. Across two half-day virtual workshops, 20 professionals from diverse disciplines, professions, and countries discussed key developments and identified opportunities for future research, with additional input via online correspondence. Participants highlighted a “frailty rehabilitation paradox” whereby pulmonary rehabilitation can effectively reduce frailty, but programs are challenging for some individuals with frailty to complete. Frailty should not limit access to rehabilitation; instead, the identification of frailty should prompt comprehensive assessment and tailored support, including onward referral for additional specialist input. Exercise prescriptions that explicitly consider symptom burden and comorbidities, integration of additional geriatric or palliative care expertise, and/or preemptive planning for disruptions to participation may support engagement and outcomes. To identify and measure frailty in people with respiratory disease, tools should be selected on the basis of sensitivity, specificity, responsiveness, and feasibility for their intended purpose. Research is required to expand understanding beyond the physical dimensions of frailty and to explore the merits and limitations of telerehabilitation or home-based pulmonary rehabilitation for people with chronic respiratory disease and frailty.

OBJECTIVES: Among critically ill patients, acutely depressed level of consciousness is associated with mortality, but its relationship to long-term outcomes such as disability and physical function is unknown. We investigated the relationship of level of consciousness during hospitalization with long-term disability and physical function in ICU survivors. DESIGN: Multi-center observational cohort study. SETTING: Medical or surgical ICUs at five U.S. centers. PATIENTS: Adult survivors of respiratory failure or shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Depressed level of consciousness during hospitalization was defined using the Richmond Agitation Sedation Scale (RASS) score (including all negative scores) by calculating the area under the curve using linear interpolation. Sedative-associated level of consciousness was similarly defined for all hospital days that sedation was received. We measured disability in basic activities of daily living (BADLs), instrumental activities of daily living (IADLs), discharge destination, and self-reported physical function. In separate models, we evaluated associations between these measures of level of consciousness and outcomes using multivariable regression, adjusted for age, sex, race, body mass index, education level, comorbidities, baseline frailty, baseline IADLs and BADLs, hospital type (civilian vs veteran), modified mean daily Sequential Organ Failure Assessment score, duration of severe sepsis, duration of mechanical ventilation, and hospital length of stay. Of the 1,040 patients enrolled in the ICU, 781 survived to hospital discharge. We assessed outcomes in 624 patients at 3 months and 527 patients at 12 months. After adjusting for covariates, there was no association between depressed level of consciousness (total or sedation-associated) with BADLs or IADLs at either 3- or 12-month follow-up. There was also no association with self-reported physical function at 3 or 12 months or with discharge destination. CONCLUSIONS: Depressed level of consciousness, as defined by the RASS, was not associated with disability or self-reported physical function. Future studies should investigate additional modifiable in-hospital risk factors for disability and poor physical function following critical illness.