Feasibility of Post-Intensive Care Unit Clinics: an observational cohort study of two different approaches.

BACKGROUND: Post-ICU clinics have been advocated to reduce long-term physical and psychological impairments among ICU survivors. A format for optimal structure, timing, and care content has not yet been established. We developed and implemented two post-ICU clinics in different hospital settings and evaluated the feasibility. METHODS: In this prospective cohort study ICU-survivors of a university hospital (AMC) and a general hospital (TG), who were mechanically ventilated ≥ 2 days and discharged to their homes, were invited to the post-ICU clinic one month after hospital discharge (AMC) or three months after ICU discharge (TG). Feasibility was evaluated as 1) the number of eligible ICU-survivors and the proportion that attended; 2) the prevalence of ICU-related abnormalities, that required referral for further treatment; and 3) patient satisfaction. RESULTS: Forty-five of 629 AMC-patients and 70 of 142 TG-patients were eligible for the post-ICU clinic. Of these, 49% and 67% respectively, visited the outpatient clinic (P=0.026). The majority of all screened patients had functional restrictions, and 68% required referral for further diagnosis and treatment. Patient satisfaction was high. CONCLUSION: This study provides valuable information to support the implementation of post-ICU clinics. The use of validated screening instruments facilitates the identification of patients with need for further treatment. Early in-hospital screening and recruiting patients at highest risk for adverse outcome could be a more targeted approach to achieve greater benefit.

Prognostic factors in the subacute phase after stroke for the future residence after six months to one year. A systematic review of the literature.

OBJECTIVE: To identify evidence-based prognostic factors in the subacute phase after a stroke for future residence at six months to one year post stroke. DESIGN: Systematic literature search designed in accordance with the Cochrane Collaboration criteria with the following data sources: (1) MEDLINE, EMBASE, CINAHL, Current Contents, Cochrane Database of Systematic Reviews, PsycLIT and Sociological Abstracts. (2) Reference lists, personal archives and consultation of experts in the field. (3) Guidelines. METHODS: Inclusion criteria were: (1) cohort studies of patients with an ischaemic or haemorrhagic stroke; (2) inception cohort with assessment of prognostic factors within the first two weeks after stroke; (3) outcome measures for future residence; and (4) a follow-up of six months to one year. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria in accordance with the recommendations of the Cochrane Collaboration. RESULTS: From 1027 potentially relevant studies 10 studies involving a total of 3564 patients met the inclusion criteria. No prognostic factor was identified in at least two level A (i.e., a good level of scientific evidence according to the methodological score) studies, our standard for scientific proof. The following factors were found in at least one level A study: low initial ADL functioning, high age, cognitive disturbance, paresis of arm and leg, not alert as initial level of consciousness, old hemiplegia, homonymous hemianopia, visual extinction, constructional apraxia, no transfer to the stroke unit, nonlacunar stroke type, visuospatial construction problems, urinary incontinence and female gender. CONCLUSIONS: At present there is insufficient evidence concerning possible predictors in the subacute stage of stroke to make an evidence-based prediction of the future residence. In the scientific research until now social factors and their contribution to the possibility of living independently have not been investigated, or at least less well. None of the studies in this review described a conceptual framework as basis for the choice of the examined prognostic factors.

Prognostic factors for ambulation and activities of daily living in the subacute phase after stroke. A systematic review of the literature.

OBJECTIVE: To identify evidence-based prognostic factors in the subacute phase after stroke for activities of daily living (ADL) and ambulation at six months to one year after stroke. DESIGN: Systematic literature search designed in accordance with the Cochrane Collaboration criteria with the following data sources: (1) MEDLINE, EMBASE, CINAHL, Current Contents, Cochrane Database of Systematic Reviews, Psyclit, and Sociological Abstracts. (2) Reference lists, personal archives, and consultation of experts. (3) Guidelines. METHODS: Inclusion criteria were: (1) cohort studies of patients with an ischaemic or haemorrhagic stroke; (2) inception cohort with assessment of prognostic factors within the first two weeks after stroke; (3) outcome measures for ADL and ambulation; and (4) a follow-up of six months to one year. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria in accordance with the recommendations of the Cochrane Collaboration. RESULTS: From 1,027 potentially relevant studies 26 studies involving a total of 7,850 patients met the inclusion criteria. Incontinence for urine is the only prognostic factor identified in three studies with a level A (i.e., a good level of scientific evidence according to the methodological score). The following factors were found in one level A study: initial ADL disability and ambulation, high age, severe paresis or paralysis, impaired swallowing, ideomotor apraxia, ideational apraxia, and visuospatial construction problems; as well as factors relating to complications of an ischaemic stroke, such as extraparenchymal bleeding, cerebral oedema and size of intraparenchymal haemorrhage. CONCLUSIONS: The present evidence concerning possible predictors in the subacute stage of stroke has insufficient quality to make an evidence-based prediction of ADL and ambulation after stroke because only one prognostic factor was demonstrated in at least two level A studies, our cut-off for sufficient scientific evidence.