Confidential

Margaret S. Herridge MSc MD FRCPC MPHProfessor of Medicine, University of TorontoScientist, University Health NetworkCritical Care and Respiratory Medicine

The RECOVER Program: One-year Outcomes in

Critically Ill Patients Mechanically Ventilated for 7 Days

Faculty Disclosures

CCCF 2015-Toronto

• Relevant financial relationships with a commercial interest:

Dr. Margaret Herridge

No relevant commercial interests.

Morbidities of Critical Illness

• ICUAW and functional disability

• Cognitive dysfunction

• Mood Disorders

Hopkins et al. AJRCCM 1999; 160:50

Hopkins et al. AJRCCM 2005; 171:340-347

Herridge et al. NEJM 2003; 348:683-93

Herridge et al. NEJM 2011; 364: 1293-304

Davydow et al. Psychosom Med 2008; 70:512-9

Unroe et al. Ann Intern Med. 2010;153:167-175

Iwashyna et al. JAMA 2010; 304 (16):1787-1794

Pandharipande et al. NEJM 2013

Hall and Kress NEJM 2014; 370: 1626-35

BUT…• Are these morbidities generalizable across a

diverse medical/surgical case mix and in the context of a multi-centre dataset?

• What is/are the optimal candidate outcome measure(s) to risk stratify and capture patient-centred disability?

• Can patients be risk stratified early post ICU to inform tailored rehabilitation programs and subsequent healthcare utilization?

Canadian Multi-Centre Interprofessional Program of

Outcomes and Rehabilitation in Patients and Family

Caregivers after Critical Illness (1 week MV)

2007-present

Phase 1: Towards RECOVER (PIs Herridge and Cameron)

6

Towards RECOVER: 1-year follow-up assessment

Patient-Centred Outcomes

• FIM - Functional Independence Measure

o Self care, sphincter control, mobility, locomotion, communication,

cognition

o Validated across different patient groupings

o Wide use in Rehabilitation Settings to document baseline and

improvement after intervention

o Score range 18-126

- FIM ≤ 40 maximal to total dependency

- FIM 50 dependent on self care

- FIM ~90 threshold for some independence in ADL

Baseline Characteristics

• 463 enrolled 391 survivors to 7d post ICU

▫ 81% follow-up of eligible visits

▫ Mean age of 58; 69% male

▫ Mean APACHE II 25

▫ Median ventilation time of 16 day (11-27)

▫ Mean ICU LOS of 22 days

▫ Mean hospital LOS 49 days

Patient Outcomes- Function7-days, 3, 6, and 12-months post ICU discharge

SF-36 Physical Component Score MRC – muscle strength

Patient Outcomes- Function7-days, 3, 6, and 12-months post ICU discharge

FIM Total Score 6MWT (% of predicted)

FIM mean scores of 54 at 7th day to

110 at 12 mo post-ICU discharge

60% of patients were unable to walk at 7 d

Walked distance from 24% to 75%pred after 12 mo

Patient Outcomes- Mood Disorders7-days, 3, 6, and 12-months post ICU discharge

BDI-II – depressive symptoms IES-R – post-traumatic stress disorder symptoms

FIM = 54n=343 (100%)

FIM = 74n=89 (26%)

FIM = 107n=20 (6%)

FIM = 68n=115 (34%)

FIM = 55n=254 (74%)

FIM = 51n=127 (37%)

FIM = 44n=78 (23%)

< 42 ≥ 42 < 45

45 - 66 ≥ 66

≥ 14 < 14

ICU

LO

S (

days)

AG

E(y

ears

)

RECOVER Disability Risk Stratification – FIM at Day 7 post ICU

Young

Short LOS

Older

Long LOS

Oldest

Long LOS

Mixed Age

Variable LOS

7-day FIM is associated with age and ICU LOS

FIM Motor Scores

Young Short LOS Mid Variable LOS Older Long LOS Oldest Long LOS

7d FIM and recovery trajectory by 4 disability risk groups

FIM Cognitive Scores

Young Short LOS Mid Variable LOS Older Long LOS Oldest Long LOS

Individual FIM Motor Tasks by 4 disability risk groupsBathing, climbing stairs and dressing upper and lower body are most

severely affected

Young Short LOS Mid Variable LOS Older Long LOS Oldest Long LOS

Individual FIM Motor Tasks by 4 disability risk groupsBathing, climbing stairs and dressing upper and lower body are most

severely affected

ICU

Survivors

Young

Short LOSMid Age

Variable LOS

Older

Long LOS

Oldest

Long LOS

Disposition At Hospital Discharge, number (%)

n=364 n=19 n=131 n=134 n=80

Home 128 (35) 13 (68) 57 (44) 43 (32) 15 (19)

Other

Hospital114 (31) 2 (11) 32 (24) 46 (34) 34 (42)

Rehab 122 (34) 4 (21) 42 (32) 45 (34) 31 (39)

Number (%) of patients with

n=398 n=22 n=137 n=147 n=92

ICU

Readmission69 (17) 1 (5) 15 (11) 26 (18) 27 (29)

Hospital

Readmission 162 (41) 8 (36) 58 (42) 63 (43) 33 (36)

Specialist

Visit188 (47) 14 (64) 69 (50) 71 (48) 34 (37)

Resource utilization by 4 disability risk groups

ICU

Survivors

Young

Short LOSMid Age

Variable LOS

Older

Long LOS

Oldest

Long LOS

Disposition At Hospital Discharge, number (%)

n=364 n=19 n=131 n=134 n=80

Home 128 (35) 13 (68) 57 (44) 43 (32) 15 (19)

Other

Hospital114 (31) 2 (11) 32 (24) 46 (34) 34 (42)

Rehab 122 (34) 4 (21) 42 (32) 45 (34) 31 (39)

Number (%) of patients with

n=398 n=22 n=137 n=147 n=92

ICU

Readmission69 (17) 1 (5) 15 (11) 26 (18) 27 (29)

Hospital

Readmission 162 (41) 8 (36) 58 (42) 63 (43) 33 (36)

Specialist

Visit188 (47) 14 (64) 69 (50) 71 (48) 34 (37)

Resource utilization by 4 disability risk groups

Major Findings• In this prospective multi-centre cohort of medical and

surgical patients with ≥1 week of MV, FIM is the most responsive, informative and patient- centred outcome compared to MRC, 6MWD and PCS of SF-36

• 60% of patients were unable to walk at 7 days after ICU discharge

• Patients may be stratified into 4 disability risk groups by age and ICU LOS which determine FIM at day 7

• Hip and shoulder girdle are most affected and this may inform specific rehab strategies

• Disability risk groups determine patterns of ICU and hospital readmission/healthcare utilization and ability to return home

Department of Occupational Science and Occupational Therapy

C r e a t i n g L e a d e r s i n O T

The RECOVER Program: One-

Year Outcomes in Caregivers

of Critically Ill Patients

Mechanically Ventilated (MV)

for 7 or more Days

Jill I. Cameron, PhD

Canadian Institutes of Health Research New Investigator

Associate Professor

Adjunct Scientist, UHN-Toronto Rehab Institute

@Caregiving_UofT

Disclosures

Jill Cameron, PhD

Has no financial or non-financial interest to

disclose.

Department of Occupational Science and Occupational Therapy

Background

Caregivers are an essential source of support to

ICU survivors

Commonly experience stress in new role

Resulting in poor health outcomes

Quality of life (Cameron, et al., 2006)

PTSD (Azoulay et al., 2005)

Emotional distress (Im, et al., 2004; Cameron et al.,

2006; Jones et al., 2004; Van Pelt et al., 2007, Douglas, et

al., 2005, Pochard et al., 2005)

Burden (Foster & Chaboyer, 2003)

Department of Occupational Science and Occupational Therapy

What we don’t know

How caregiver depression changes over time

How patient, caregiver, and caregiving

related factors interact to affect caregiver

depression

Department of Occupational Science and Occupational Therapy

Objectives

1) determine the percentage of caregivers at

risk for clinical depression during the first

year post-ICU discharge

2) identify groups of caregivers who have

different courses of depressive symptoms

over the first year post-ICU discharge

3) identify patient, caregiver, and caregiving

situational factors that influence caregiver

depression

Department of Occupational Science and Occupational Therapy

Department of Occupational Science and Occupational Therapy

Caregiver Characteristics

~70% female

53 (13.4) years of age

Caring for spouse (60%)

Married (83%)

Completed post-secondary (51%)

Working for pay (59%)

Department of Occupational Science and Occupational Therapy

Caregivers

at Risk for

Clinical

Depression

Patterns of Group Change over

Time

Trajectory Groups

Did not differ by

Caregiver sociodemographics, living

arrangements, previous caregiving

Patient sociodemograhpics, ICU LOS,

APACHEII, comorbidity, 6MWD, 7-day FIM

Persistent High Group CG 7-day

Less Mastery and Social Support

More Assistance and Impact

Department of Occupational Science and Occupational Therapy

Multivariable Look at Caregiver

Depression

Patient Factors

NOT:

patient age

ICU LOS

Comorbidity

6MWD

FIM-motor

FIM cognitive

Department of Occupational Science and Occupational Therapy

Caregiving Factors

Lifestyle Impact

Less Social support

Less Mastery

Less Personal Gain

Younger age

Non-spouse

Less education level

Less income level

Conclusions

Caregivers at high risk for clinical depression

Large percentage improve over time

Small percentage maintain high levels of

depression

Depression related to caregiver factors NOT

patient factors

Caregivers are a unique group in need of

support and intervention

Department of Occupational Science and Occupational Therapy

Susan Abbey

Najib Ayas

Neill Adhikari

Jane Batt

Mark Bayley

Laurent Brochard

Leslie Chu

Deborah Cook

Brian Cuthbertson

Marcelo Cypel

Claudia Dos Santos

Eddy Fan

Niall Ferguson

John Flannery

Rob Fowler

Jan Friedrich

Paul Hebert

Shaf Keshavjee

Melanie Levasseur

Francois Lamontagne

Christie Lee

Vincent Lo

John Marshall

Sunita Mathur

Andrea Matte

Hilary Meggison

Sangeeta Mehta

Jill Rudkowski

Gordon Rubenfeld

Damon Scales

Tasnim Sinuff

Yoanna Skrobik

Arthur Slutsky

Adrienne Tan

Claire Thomas

George Tomlinson

Liz Wilcox

RECOVER Program (Phase 1:Towards RECOVER)

PIs: Drs. Margaret Herridge and Jill Cameron Leslie Chu, Linda Chan, Claire Thomas, Stacey Burns, Andrea Matte,Priscila Robles

Research Coordinators

UHN (TWH)- Andrea Matte, Paulina Farias, Cheryl Geen-Smith

MSH - Cheryl Ethier, Maedean Brown, Brittany Giacomino and SumeshShah

SMH - Orla Smith, Yoon Lee, Kerri Porretta, Julia Lee and Melissa Wang

SHSC - Nicole Marinoff, Jane Wang, Derek Parsotam and AshwatiRaghunath

SJH - Andrea Tkaczyk and France Clarke

OHSC - Mary-Jo Lewis, Tracey McArdle and Brigette Gomes

SPH - Lynda Lazosky, Ellen Woo

CHUS - Chantal Langevin, Karine Grondi, Joanie Lacasse-Bedard and Eugenie Pinsonnault

HMR - Johanne Harvey