Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) Results and Findings

What were we trying to achieve? Improved Quality of Life in this group Empower patient to take control of their health and wellbeing Increase Return to Employment by 20% Decrease GP visitation by 20% Patient Satisfaction

EQ-5D (Quality of Life)

How did we measure impact? Historical control group (2009-2010) Similar follow up dates to our population (One to two year post ICU discharge).

Patient Empowerment Generalised self-efficacy tool The scale ranges from 10-40 (10 lowest possible self-efficacy and 40 being highest achievable score) Self-efficacy measurements were undertaken at baseline (start of clinic), week 5 of the clinic at six months and at 12 months. Important Concept: We know that Self Efficacy is related to QoL.

Increase Return to Employment by 20% Again, Historical control group Who got back to work at one year?

Decrease GP visitation by 20% How many patients regularly had contact with their GP at one year Within one cohort, it became apparent that we were increasing GP visitations! Empowerment Did we improve the quality of visits?

Patient Satisfaction Undertaking qualitative interviews Purposive sampling 11 patients and caregivers at 6 months Thematic analysis utilised

Statistical analysis R (Version 3.3.0) for statistical analysis . Continuous variables were expressed as medians and inter quartile ranges and analysed using the Mann-Whitney U test Categorical variables were compared using chi squared tests   All tests were two sided and a p value of less than 0.05 was considered significant Multi- variable regression to adjust for differences between the groups (historical control vs. InS:PIRE cohort).

48 patients took part in InS:PIRE over the one year learning period 2 patients ≥65 years and excluded from analysis 2 patients passed away in the follow up period 1 patient new diagnosis of cancer and did not want to continue with programme 2 of these patients had alcohol dependency 3 patients did not complete EQ 5D at one year 40 patients at one year analysed 87% follow up rate

Patients Patient Characteristic n=46 Gender (Male, %) 65.2% Age (years, median, IQR) 51 (43-57) ICU LOS (days, median, IQR) 15 (9-26) APACHE II (median, IQR) 23 (18-27) Charlson Co-Morbidity Index (median, IQR) 1 (0-2) Patients with Mental Health Problems Pre ICU (%) 45.7 SIMD Decile (median, IQR) 3 (1-4) Hospital LOS (days, median, IQR) 47 (24-80) Proportion Ventilated (%) 93.5 Proportion undergoing RRT (%) 34.8 Proportion undergoing CVS (%) Employed Pre-ICU admission (%) 41.3 Retired Pre-ICU (%) 10.9 Unemployed Pre-ICU (%) 43.5 HUS Clinic Baseline (median, IQR) 0.364 (-0.041-0.689) HUS One Year (median, IQR) 0.620 (0.320-0.726)

Self Efficacy Baseline median of SE 25.5 (IQR 19.75-30.25) to 28.5 (IQR 26- 33.75) at five weeks (p=0.003). This was sustained at one year post InS:PIRE- median SE score of 29 (IQR 26-32).

Quality of Life (QoL) Compared the historical control group and the InS:PIRE cohort Working age population only.

InS:PIRE cohort vs. Historical control Patient Characteristic InS:PIRE cohort (n=46) Historical Control (n=53) p value Gender (male %) 65.2 58.5 0.63 Age (years, median, IQR) 51 (43-57) 47 (40-52) 0.16 ICU LOS (days, median, IQR) 15 (9-26) 3 (1-10) <0.001 APACHE II (median, IQR) 23 (18-27) 14 (9-19) Charlson Co-Morbidity Index (median, IQR) 1 (0-2) 0 (0-2) 0.35 Patients with Mental Health Problems Pre ICU (%) 45.7 39.6 0.69 SIMD Decile (median, IQR) 3 (1-4) 2 (1-5) 0.31 Hospital LOS (days, median, IQR) 47 (24-80) 25 (11-50) 0.002 Proportion Ventilated (%) 93.5 79.2 0.12 Proportion undergoing RRT (%) 34.8 13.2 0.03 Proportion undergoing CVS (%) 17.0 0.005 Employed Pre-ICU admission (%) 41.3 47.2 0.07 HUS (Median, IQR) 0.620 (0.320-0.726) 0.516 (0.024-0.7100) 0.26

Multivariable regression Factors that impact recovery Charlson Co- morbidity SIMD Work Pre-ICU

Multivariable Analysis For those who undertook the InS:PIRE programme there was a significant increase in their HUS after adjustment for social factors pre ICU (SIMD, Charlson Co-morbidity, in work pre-ICU) (0.16; 95% CI 0.011-0.305; p=0.04) Variable Estimate   p value Charlson Score -0.06 (-0.114 - -0.008) 0.024 SIMD decile 0.03 (0.006-0.573) 0.017 Working Pre ICU 0.18 (0.024- -0.057)

Qualitative analysis Support Psychological Impact Physical Impact Future Direction Patient volunteers provided hope, optimism and peer support. Understanding of symptoms and coping mechanisms Increased confidence and independence Longer time/balance of dependency Staff (MDT) – cohesive approach Family benefit Use of goals/personal goals Importance of follow up Created a community Feeling normal, acknowledgement of illness Importance of involving carers  

Support-Patient Volunteers ‘It’s good to see how far somebody who has been so ill like yourself can improve and recover over a period of time.’

Psychological Impact- Feeling Normal ‘..it was so good to know that you were normal. I didn’t feel like an abnormal person anymore, I felt like everything I was feeling was a normal reaction.’

Physical Impact- Goal Setting ‘I was nervous in case I didn’t achieve them and then coming back today to realise that I have actually overachieved a couple….it was a good thing because I would not have set goals for myself’.

Return To Work Pre ICU 17 of the 40 patients employed pre ICU (42.5%) 4 retired (10%) 19 unemployed/chronically unwell pre ICU(47.5%) Post InS:PIRE 8 patients returned to employment or volunteering roles after ICU (71%) vs 64% in historical control group. One patient voluntarily retired (2.5%) Those who weren’t in work pre ICU, 3 (7.5%) in volunteering roles.

Limitations Single entre Small sample- not powered Learning project- patients at different stages of recovery trajectory

Conclusion InS:PIRE is a safe, appropriate, person centred programme which patients and caregivers feel is beneficial Over the five weeks of InS:PIRE, patients felt more in control of their health and wellbeing Those patients who have undergone the InS:PIRE programme appear to have a significantly better QoL than those patients who have not.

Thanks! Health Foundation Health and Social Care Alliance Citizens Advice Bureau (Maryhill and Possilpark) Glasgow Council for the Voluntary Sector (GVCS) Carers Centre (NHS GG&C and Glasgow City Council) Quality Unit at the Scottish Government All the patients who took part

We enjoyed last Thursday, we miss coming up to see you all .........We enjoyed last Thursday, we miss coming up to see you all. Thanks for giving us our lives back Liz x