Scientific Letter
Detection of frailty and palliative needs from discharged critical care patients in collaboration with primary care
Detección al alta de UCI de la fragilidad y necesidades paliativas del paciente crítico en colaboración con atención primaria
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Ferré, S. Canelles, X. Daniel, O. Rubio, F. Esteban, A. Pobo" "autores" => array:6 [ 0 => array:3 [ "nombre" => "C." "apellidos" => "Ferré" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Canelles" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "X." "apellidos" => "Daniel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "O." "apellidos" => "Rubio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "F." 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"apellidos" => "Pobo" "email" => array:1 [ 0 => "apobo.hj23.ics@gencat.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Universitari Joan XXIII, Institut d’Investigació Sanitària Pere Virgili, University Rovira i Virgili, CIBERES, Tarragona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Sant Joan de Déu, Fundació Althaia Xarxa Universitària, Manresa, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Detección al alta de UCI de la fragilidad y necesidades paliativas del paciente crítico en colaboración con atención primaria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1746 "Ancho" => 2917 "Tamanyo" => 269204 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Progression over time of ISIP and ADP of the CCPs and ACCM during the year of follow-up.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">PCC: Paciente Crónico Complejo; MACA: Enfermedad Cronicidad Avanzada; PIIC: Plan Intervención Individualizado Compartido; PDA: Planificación Decisiones Anticipadas.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Our population is growing older, and this implies an increase in age-related chronic diseases. As a result, we have a growing number of elderly persons with multiple health problems and with a poor functional reserve.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> All this indicates that the number of frail individuals in the Intensive Care Unit (ICU) will continue to rise.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Such patients present greater disability at the time of discharge, are more likely to be admitted to a sociosanitary center, and experience greater mortality and longer convalescence periods.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In view of the above, early detection of frailty is needed, and we should be aware of the prognostic usefulness of frailty as a complement to the usual mortality-centered scales employed (APACHE, SAPS3, etc.). In this way we could redirect our efforts to ensure earlier empathic and honest conversations focused on the shared planning of care, respecting the desires, preferences and values of our patients and their relatives.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In addition, the detection of frailty at discharge from the ICU could be of help in continuous clinical decision making and in improving the efficiency of the healthcare system.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Health Plan<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> of Catalonia (Spain) 2011–2015 sought to place priority on prevention and care in people with advanced chronic disease conditions. The primary care teams (PCTs), using the NECPAL (<span class="elsevierStyleItalic">NECesidades PALiativas</span> [Palliative Needs]) tool,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> identified two frail person profiles: complex chronic patients (CCPs) and patients requiring an advanced chronicity care model (ACCM), with the idea of adopting an individualized care plan (Individualized Shared Intervention Plan [ISIP]) including advanced decision planning (ADP). All this in turn is recorded in the shared case history of Catalonia (SCHC) with the purpose of facilitating decision making.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The NECPAL tool was designed by the Qualy-ICO-CCOMS observatory, and has been validated in our setting for the identification of people with advanced chronic disease, an estimated life expectancy of 12 months, and a need for palliative care of some kind – the activation of specific plans therefore being necessary<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> (Appendix <a class="elsevierStyleCrossRef" href="#sec0010">B</a>, see Supplementary material).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the new populational paradigm, the important and persistent barriers facing decision making regarding the adequacy of life support care (ALSC) and end-of-life care,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which obliges intensivists to decide in this regard, and in concordance with the Health Plan<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> of Catalonia, we decided to be more proactive in detecting these patients, conducting prognostic follow-up and seeking to ensure early detection of their predictable palliative needs.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this context, over a period of 6 consecutive months and in all patients discharged from our ICU, we determined whether they were identified as CCPs or ACCM, and whether they had ISIP and/or ADP. If the patients were identified but did not have ISIP and/or ADP, interconsultation of the liaison nurse with the PCTs was made, recording the time to implementation of the ISIP and/or ADP. In turn, based on the NECPAL, we identified those patients in need of palliative care, reporting them to the LN to facilitate their identification as CCPs or ACCM and implementation of the ISIP and/or ADP. Lastly, during one year of follow-up, we checked how many patients were finally catalogued and whether they had their ISIP and/or ADP.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study was approved by the Ethics Committee of our center. Since no interventions different from those of routine practice were involved, informed consent from the patients or their representatives was not considered necessary.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Of the 471 discharged patients, 24.6% (n = 116) were NECPAL positive, with a predominance of males (66.4%, n = 73) and a mean age of 66.3 ± 13 years. The mortality rate at one year was 28.9% (n = 33). Of all the subjects, 16 (13,7%) were previously CCPs (n = 14) or ACCM (n = 2), and 9 (56.2%) had their ISIP, while only one of them moreover also had ADP. After the year of follow-up and the pertinent LN interconsultations, a total of 10 ISIP (62.5%) and 4 ADP had been established (25%). Of the other 100 NECPAL positive patients at discharge, information corresponding to the SCHC could not be obtained in 5 cases, thus leaving 95 patients. At one year, 25.2% of them (n = 24) were catalogued as CCPs (n = 20) or ACCM (n = 4) by the PCTs, though 75% (n = 18) had been catalogued as such at 6 months. In this same period of time almost 60% (58.3%, n = 14) of the ISIP were established, together with the only two ADPs registered during the entire year of follow-up (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Previous experiences with the NECPAL<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> tool are available in other populations for detecting chronic patients with palliative care requirements,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and even in seeking to predict their mortality.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> To our knowledge, however, this is the first time the mentioned tool is used to detect the palliative needs of patients at discharge from the ICU and to try to implicate the professionals of the PCTs.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Although a range of scales have been validated in different populations to measure frailty,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> none of them have sufficient discriminating capacity to be universally used in the ICU. Until such a tool becomes available, the best approach is to use the scale that is most feasible in our setting and which allows us to make the best decisions regarding our patients. In our healthcare setting it makes full sense to use the NECPAL,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> for in addition to already having been validated and allow multimodal assessment (including comorbidities, subjective aspects of demand or need for palliative care, and clinical severity, disease progression, nutritional, functional, social, emotional distress and resource utilization indicators), it can be consulted and shared by means of the SCHC.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The World Health Organization (WHO) recommends addressing frailty, individual preferences, priorities and psychosocial resources, and incorporation of the latter to the individualized planning of care, since these factors influence individual patient quality of life.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The few ADPs established initially and at one year of follow-up offer important room for improvement which we should take advantage of.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In view of its prognostic importance, the detection of frailty should be incorporated to our routine clinical practice in order to adequately adjust life support management both upon admission to and at discharge from the ICU. In addition, this would allow us to implement early palliative care strategies and – where needed – to provide adequate end-of-life care.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ferré C, Canelles S, Daniel X, Rubio O, Esteban F, Pobo A. Detección al alta de UCI de la fragilidad y necesidades paliativas del paciente crítico en colaboración con atención primaria. Med Intensiva. 2022;46:101–103.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0075" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0010" ] ] ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1746 "Ancho" => 2917 "Tamanyo" => 269204 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Progression over time of ISIP and ADP of the CCPs and ACCM during the year of follow-up.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">PCC: Paciente Crónico Complejo; MACA: Enfermedad Cronicidad Avanzada; PIIC: Plan Intervención Individualizado Compartido; PDA: Planificación Decisiones Anticipadas.</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 131608 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The challenge admitting the very elderly to the intensive care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y.-L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 3 | 4 |
| 2024 October | 48 | 52 | 100 |
| 2024 September | 39 | 46 | 85 |
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| 2023 December | 42 | 34 | 76 |
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| 2023 September | 27 | 37 | 64 |
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| 2023 July | 39 | 27 | 66 |
| 2023 June | 24 | 17 | 41 |
| 2023 May | 52 | 33 | 85 |
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| 2023 March | 49 | 27 | 76 |
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| 2022 December | 53 | 55 | 108 |
| 2022 November | 65 | 39 | 104 |
| 2022 October | 50 | 32 | 82 |
| 2022 September | 45 | 33 | 78 |
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