Background Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about their patterns of care as they transition from the acute hospital to post-acute care facilities or the associated resource utilization. Objectives To describe one-year trajectories of care and resource utilization for prolonged mechanical ventilation patients. Design One-year prospective cohort study. Setting 5 ICUs at Duke University Medical Center. Participants 126 prolonged mechanical ventilation patients as well as their 126 surrogates and 54 ICU physicians were enrolled consecutively during one year. Prolonged mechanical ventilation was defined as ventilation for ≥4 days with tracheostomy placement or ventilation for ≥21 days without tracheostomy. Measurements Patients and surrogates were interviewed in hospital, as well as 3 and 12 months later to determine patient survival, functional status, and facility type and duration of post-discharge care. Physicians were interviewed in-hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and inter-facility transportation. We used Medicare claims data to assign costs for post-acute care. Results 103 (82%) hospital survivors experienced 457 separate transitions in post-discharge care location (median 4 [interquartile range 3, 5]), including 68 (67%) patients who were readmitted at least once. Patients spent an average of 74% (CI, 68% to 80%) of all days alive in a hospital, post-acute care facility, or receiving home health care. At one year, 11 (9%) patients had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency (n=4, 21%) or dead (n=56, 44%). Patients experiencing a poor outcome were older, had more comorbidities, and were more frequently discharged to a post-acute care facility than patients with either fair or good outcomes (all p <0.05). Costs per patient were $306,135 (SD $285,467) and total cohort costs totaled $38.1 million, for an estimated $3.5 million per one-year independently functioning survivor. Limitations The results of this single center study may not be applicable to other centers. Conclusions Prolonged mechanical ventilation patients experience multiple transitions of care, resulting in extraordinary health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support.

Background: After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when, remain unclear. Objectives: Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for post-discharge impairments. Participants: 31 international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine's (SCCM) Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers. Design: SCCM consensus conference on post-intensive care syndrome (PICS) prediction and assessment, held in Dallas, in May, 2019.Meeting Outcomes: We concluded that existing tools are insufficient to reliably predict PICS. We identified factors before (e.g., frailty, pre-existing functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder (PTSD)) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2-4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment

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Objective: Prolonged mechanical ventilation (PMV) provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the PMV decision making process could provide an explanation to this phenomenon. Therefore, we aimed to compare PMV decision makers' expectations for long-term patient outcomes with prospectively observed outcomes. Design, Setting, and Patients: 126 patients undergoing PMV, their surrogates, and their intensive care unit physicians were enrolled consecutively (total n=378) at an academic medical center between April 2006 and April 2007 and followed prospectively for one year. Measurements: Participants were interviewed at the time of tracheostomy placement about their expectations for one-year patient survival, functional status, and quality of life. These expectations were then compared to observed one-year outcomes measured with validated questionnaires. Results: One-year follow up was 100%, with the exception of patient death or cognitive inability to complete interviews. At one year, only 11 (9%) patients were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for one-year patient survival (117 [93%]), functional status (90 [71%]), and quality of life (105 [83%]). In contrast, fewer physicians described high expectations for survival (54 [43%]), functional status (7 [6%]), and quality of life (5 [4%]). Surrogate-physician pair concordance in expectations was poor (all κ<0.08), as was their accuracy in outcome prediction (range 23-44%). Just 33 (26%) surrogates reported that physicians discussed what to expect for patients' likely future survival, general health, and caregiving needs. Conclusions: One-year patient outcomes for PMV patients were significantly worse than expected by patients' surrogates and physicians. Lack of prognostication about outcomes, discordance between surrogates and physicians about potential outcomes, and surrogates' unreasonably optimistic expectations appear to be potentially modifiable deficiencies in surrogate-physician interactions.

Objective-Survivors of the acute respiratory distress syndrome (ARDS), a systemic critical illness, often report poor quality of life based on responses to standardized questionnaires. However, the experiences of ARDS survivors have not been reported. Our objective was to characterize the effects of critical illness in the daily lives and functioning of ARDS survivors.Design, Setting, and Patients-We recruited consecutively 31 ARDS survivors and their informal caregivers from medical and surgical intensive care units of an academic medical center and a community hospital. Eight patients died before completing interviews. We conducted semistructured interviews with 23 ARDS survivors and 24 caregivers three to nine months after ICU admission, stopping enrollment after thematic saturation was reached. Transcripts were analyzed using Colaizzi's qualitative methodology to identify significant ways in which survivors' critical illness experience impacted their lives.Measurements and Main Results-Participants related five key elements of experience as survivors of ARDS: pervasive memories of critical care, day to day impact of new disability, critical illness defining the sense of self, relationship strain and change, and ability to cope with disability. Survivors described remarkable disability that persisted for months. Caregivers' interviews revealed substantial strain from caregiving responsibilities, as well as frequent symptom minimization by patients. Conclusions-The diverse and unique experiences of ARDS survivors reflect the global impact of severe critical illness. We have identified symptom domains important to ARDS patients that are not well represented in existing health outcomes measures. These insights may aid the development of targeted interventions to enhance recovery and return of function after ARDS. Corresponding author and reprints:

Graduating nursing and medical students missed several hazards of hospitalization, especially those related to the intensive care unit. Orientation for residents and new nurses should include education on hospitalization hazards. Ideally, this orientation should be interprofessional to allow appreciation for each other's roles and responsibilities.

Objective: Patients and caregivers can experience a range of physical, psychological, and cognitive problems following critical care discharge. The use of peer support has been proposed as an innovative support mechanism. Design: We sought to identify technical, safety and procedural aspects of existing operational models of peer support, among the Society of Critical Care Medicine Thrive Peer Support Collaborative. We also sought to categorize key distinctions between these models and elucidate barriers and facilitators to implementation. Subjects: 17 Thrive sites from the USA, UK, and Australia were represented by a range of healthcare professionals. Interventions: Via an iterative process of in-person and email/conference calls, members of the Collaborative, defined the key areas on which peer support models could be defined and compared; collected detailed self-reports from all sites; reviewed the information and identified clusters of models. Barriers and challenges to implementation of peer support models were also documented. Results: Within the Thrive Collaborative, six general models of peer support were identified: Community based, Psychologist-led outpatient, Models based within ICU follow-up clinics, Online, Groups based within ICU and Peer mentor models. The most common barriers to implementation were: recruitment to groups, personnel input and training: sustainability and funding, risk management and measuring success. Conclusion: A number of different models of peer support are currently being developed to help patients and families recover and grow in the post-critical care setting.

Debriefing sessions using checklists can be successfully implemented in ICU rotations. Checklists can be used to assess both resident performance and consistency of practice with respect to published standards of care in critical care medicine.