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Hi, good, good evening, everybody. Welcome to this uh six evening education update. Um uh We are delighted this evening to welcome Doctor Philip Henderson along to talk about post intensive care syndrome and the inspired cohort. Um If you'll indulge me a little bit, I know many of you will be members of the Scottish Intensive Care Society, but just um a um the Scottish Intensive Care Society is designed to coordinate and represent the specialty of I CM in Scotland. And really the the activities focus on education, research and audits. And there are various categories of membership for all different kinds of healthcare professional. And there are a number of benefits of membership including a reduced rate at meetings, comprehensive transfer insurance. Um And if you're, if you're interested, there will, there will soon be education travel bursaries advertised, which can be really useful if you're looking to undertake either travel or, or some research. Um So to introduce our speaker for this evening, Dr Henderson is a consultant in intensive care medicine and anesthetics at the Rh in Paisley. He runs the inspire follow up program there um which has been on the go for some time for four years now. Um Although he credits his colleagues with a lot of help for that. And most importantly, the ICU nurses and admin staff there, he took some time out of training to research long term outcomes after critical illness. And Tara Joe mcpeak and Martin Shaw helped to guide him through that endeavor with help from the Health Foundation in the University of Glasgow. Uh His interest at that point was around quality of life measures for patients and caregivers. One year after their critical state, a critical care stay in general and cardiothoracic ICU. And that led to some really impactful research output. And he also got the opportunity to provide some excellent undergraduates and critical care related projects. And if he isn't working, you'll find him up a hill, either in walking boots or on skis. So, thank you so much, Doctor Henson for joining us a member without further. I'll hand over to you. OK. Thanks Jelly. Um So, yep, everyone should be able to hear me. OK, and see my slides. So I was just gonna go through um some aspects of post intensive care and er the Inspire Project. So basically three sections, hopefully get through it in about 50 55 minutes. Um We'll chat about post intensive care syndrome and what it is and some of the background to that. Um And where, where the kind of evidence has gone, got to chat about the Inspire program and what that involves um and what we did there and then look at the outcomes of the studies that Jelly mentioned that I looked at. So basically, looking at the one year outcomes in groups of patients who went to inspire and those that did not, I think I can see the chat. So if I become skilled at multitasking, feel free to write something and I'll try and feedback. If not, we'll have questions and things at the end. So it's been a for a long, long time, basically, since the birth of intensive care, it's been pretty obvious that life and death, which are the, I guess the easier things to method to measure. And there's those sort of things that we look at regularly in intensive care, but it's maybe not just that. So quality of life is really important. So even if you go back and get quotes from the eighties and things where life and death isn't the only important thing, that's the quality of life that um we restore in intensive care. And I think it took us a long time to formalize these thoughts about quality of life or how do we measure function and things after intensive care? Um And really, it wasn't till basically this century that we started measuring things properly. So a big driver for this was the Society for Critical Care Medicine uh in the States. So they convened a meeting uh in 2010 and they basically coined this concept of post intensive care syndrome. Up to that 0.20 10 people done lots of research on it. Uh People like Margaret Herridge, Herridge, who go to mention later, but clearly a problem had been identified that people were surviving intensive care. But actually, there was a lot more to it than that. Um So this term post intensive care syndrome was coined part of their purpose for doing that was basically to say, look um more research needs to be done. And actually, I think they achieve their goals with that. So over the sort of next decade from 2010 to 2020 there was an absolute proliferation and research, including like there was one study that looked at what tools had been used to measure outcomes from intensive care and 250 different measurement tools or surveys have been used. So people actually hit the ground running. And I think in terms of coining this phrase and creating this sort of momentum to to get this body of research underway, I think they achieve their goals admirably since then, the society Criticare Medicine have actually pushed things on beyond that. So we don't quite have a core outcome set. Um but we have probably closer to these are the things you should be measuring if to look at quality of life and or um outcomes beyond just life or death after intensive care. And, and just before the pandemic struck, uh the the same sort of group met up with a few new members. Um And they tightened up kind of that definition and how we measure things. So this was the term or this is the definition that they came up with at that time. So, and it still holds true. Uh What 13 years on now from the original definition. So post intensive care syndrome, if you're not aware, would be defined as new or worsening problems in physical health, cognitive function or new cognitive impairments, uh and new or worsening problems in mental health. These would be problems that arise after critical illness um are are noticed after critical illness and they persist beyond acute hospitalization. So patients who are home or in another health care facility, but they've left the hospital with left intensive care and the term can be applied to the patient or their family member. So then we get this concept of two aspects of post intensive care syndrome. And so PS would be relating to the Survivor and that's what we're talking about with the mental health, cognitive impairments or physical impairments. And PF would be um the pics in the family member. So that's primarily related to mental health problems. Although um the the range of issues that family members can have is huge afterwards as well. Um About 2017, there was a pediatric fix that was also defined, but I've not looked at that much and I've focused very much on the PS and PI F. But as you can see, this is the original conceptual diagram and the range of problems is quite broad under each subheading. So whether that's anxiety, depression ptsd, um cognitive impairments can be memory attention, visuospatial and physical impairments, um which actually has been one of the hardest things to define or look at in terms of uh pulmonary function, neuromuscular physical function. But we're probably moving towards a more global measure for physical impairments. Um but that's how you would define it. Those would be the sort of main domains of post intensive care syndrome. And so that was the original sort of 2010 definition that, that was published in 2012 and 2019, er, the same sort of group met up. Er, and the main thing I wanted you to focus on was the middle column here that actually after a decade of kind of everyone just out the blocks searching for stuff um measuring whatever they could um things have been tightened up. So it's not quite a core outcome set of these aren't the things we have to measure afterwards. But if you wanted to go looking for these problems, this is probably the, the areas you'd look at. So um the Montreal cognitive assessment tool, the mocha hospital anxiety and depression scale for posttraumatic stress, they recommend uh impact of event scale. There are two different versions that are of the six, the physical function. One is the one that people really struggle most to define or, or see what we should measure and they're obviously very focused, things like pulmonary function tests and things like that. But it seems like global assessments of physical function are probably where we're at and that's probably what you want to be looking at. So six minute walk test, which to me, it is not a very patient centered outcome, but it's kinda, it feels a little bit more objective granted, it's dependent on the patient putting in effort and things for those six minutes. But it feels like from a medical point of view, we get a number. How far did they walk in six minutes and then the Euroquol. So the EQ five D is probably one that's um been repeated many times and is quite robust and that's got five main areas. It's basically a survey looking at patients um limitations in mobility, self care, usual activities, pain or anxiety and depression. Um And that's a pretty well validated international tool. It's probably good for focusing our mind on the kind of overall physical function of the patient. So that's the definition that's what post intensive care syndrome is. And that's the kind of journey that I guess the society of Critical Medicine have been on in terms of trying to focus, I guess the researchers and the the sort of community as a whole and focusing on what we should be looking at for long term outcomes. Um there have also been suggested risk factors because obviously, um we're all, we all work in intensive care here and we like to think things we do can make a difference. So, um they've come up with various risk factors. So, cognition, biggest of that is pre existing cognitive dysfunction, you're more likely to have worse cognitive function afterwards if you had a problem beforehand, uh delirium is a huge issue and I'll show you a paper later on that looks at uh cognitive function related to delirium sedation and perhaps benzos and then other markers of, of um severity of illness, sepsis, shock, hypoxia, and mental health. Um Obviously, there, you can see there are risk factors in every column. It's basically preexisting problems and then early signs that the patient might be developing a problem. So if an ICU or very soon afterwards in the hospitalization phase, they've got these recurring memories, this sort of early ptsd type pattern, then they are more at risk of having long term as in the beyond three months um problems. Uh And if they have early anxiety, depression PTSD, they're more likely to have the long term sequelae of that. Um, notice the massive gaping hole um under the physical component for during ICU and after critical illness, it's very hard to define risk factors for new or worsening physical impairments during or after critical illness. I think a lot of that is because it's, it, it's so broad, but B can be so focused as well. So, um you might be limited by your cardiovascular health, you might be limited by your loss of skeletal muscle mass and your frailty. Um, or you might have a BS and a long sequelae to that. So it's hard to see what happens during critical illness. How does that affect the long term physical health? And certainly no one's been able to come up with good or reliable sort of um predictors or risk factors during ICU or immediately after ICU for that. But beforehand, going in the worse, your functional physical health is the more frail you are. And interestingly, cognitive impairment. Um it makes you more likely to have a physical impairment afterwards. So cognitive dysfunction appears across the board almost. So those are the risk factors. Those are some of the areas we could target either before during or immediately after I see you. Um So that's the definition of post intensive care syndrome. That's some of the risk factors and some of the things we think um affect these long term outcomes. So I thought I would take you through a few interesting papers, not necessarily um covering everything, but just a few of the, you know, the main names are those that are um significant in terms of numbers or methodology. So if we look at the physical outcome, so this is Margaret Herridge. So um her group, she's a Canadian intensivist who um started a lot of this and a lot of hard work started in the early naughty before there even was the term post intensive care syndrome. She generally looked at the group, generally looked at um A R DS. So I guess it was a subgroup of our intensive care, but probably one of the main diseases or one of the main reasons why people end up in intensive care. A lot of her stuff or a lot of the group stuff was focused on the physical outcomes. So, um as you can see here, so we've got this sort of a Kaplan Meer type at the top and survival, but next time, so this is the six minute walk test. And I guess the reason I show you this is to show you that this physical recovery over the 1st 18 months is actually it's fairly rapid, but it does continue for that length of time. So people coming out of ICU which is day zero and these are only survivors. Um They will continue to improve physically for quite some time, but then we'll hit a plateau and that'll happen right about the 18 months to two year mark. Um The plateau is generally less so 70 below 75% of the predicted value. Um And generally doesn't seem to get much better from there. So that's a six minute walk test. And on the right, we have something called an SF 36. It's just another survey, don't worry. About its name. But um the physical component scale is what I wanted to show you and you can see that matches the six minute walk test. So for the 1st 18 months, you get that much steeper angle to the point that patients then reach about the one standard deviation level by the two year mark and then seem to plateau out half the there. So that's almost like the more objective measure the six minute walk test and then the more subjective measure of a questionnaire, how, how, how are you functionally? Um I've not shown you the, they did a whole battery of other tests in this study. So this is five years follow up. It was written in er, or published in 2011. Um They did other things. So things like pulmonary function, even in A R DS, it generally normalizes and, and certainly there might be a few outliers who have persistent abnormalities in their pulmonary function, but on the whole patients recover and those sort of objective numerical measures get better and don't seem to be a lasting problem. But despite that patients still have a lasting problem in either things you survey them in or uh when measuring a six minute walk test. So we can't tie this together with er DS causing a severe respiratory problem. Um And there's definitely a lot more to it than that. Um And comorbidity is definitely really important. So this is just another graph from from that same paper and saying that over the five years after intensive care, if you've got comorbidities, then you're more likely to spend, have more health care costs over the next five years, which is probably pretty obvious, but I think it's interesting to see it written down, interesting to see that there. Um, and maybe highlight some of those risk factors that if you've got preexisting problems, you're more likely to have uh ongoing problems. So, um intensive care does seem to be an inflection point when the patient enters that to make things can get a lot worse and they take a long time to recover. Um But you obviously where you start from, your baseline is very important as well. Um And, and also alongside that, it's, it's a target where we can focus things and say, look, there are groups of patients that after ICU um have huge expenditure and somewhere like North America is pretty good for measuring this sort of thing because of their health care system. Um So that's physical function, physical function is hard to measure, it takes a while to um to kind of recover. You can recover, you keep recovering for 18 months, two years, then plateau out. Um And respiratory function is not gonna give us all the answers, I guess is the summary there moving on to mental health outcomes. So the reason I've chosen this study is just the sheer size and I guess the relevance to our population. So almost 5000 patients were surveyed from the C A data. So, England and Wales um there are you poke loads of methodological flaws in this paper but actually the numbers hold true when you look at small studies that act that look at um the outcomes, er they get similar results basically. Um So this one's notable just because it's absolute size, the 5000 patients post ICU um so anxiety rates over the first year were 46% depression, 40% and PTSD 22% anxiety, depression was measured using HS the hospital anxiety and depression scale just as a reference range. So um the UK government would, when they survey, they do random surveys on the general population, they would say mental health disorders occur in 15.7%. They've got their own survey that's similar to HS but isn't exactly HS um and then hads depending on what survey you read and study, you could get um positive er positive results for anxiety, depression anywhere between six and 30% of those you study. So definitely mental health problems are more common after intensive care um than they are in the general population. So we can say that with, with a reasonable amount of certainty, the grafts on the right hand side, they just split them up into different categories. Green is no uh mental health problem. Yellow is mild, orange um is, is moderate and red is severe So they're giving you the figures for moderate and above there. So even the moderate level of anxiety, depression is probably higher than the general population. And the yellow cut off is kind of the standard um that we would use when measuring uh using the hospital anxiety and depression scale. And the bottom one is PTSD. So rates of 16 18% depending on whether you measure things at three or 12 months. Um So mental health problems are common after IC um ICU and they also have a other impact. So this study looked at um mortality in the two years after ICU and they looked for um associations to that. And the strongest association they got was those who scored positive um for depression on had score were 47% more likely to die in the first two years. And that was statistically significant uh with the confidence and not crossing. Um And also of interest was basically PTSD does not occur on its own. So we've got one little slither here of 1% where people who score positively for PTSD and don't score positively for um depression or anxiety. But um if you were going to be sort of pragmatic and measure the minimum things you can, then probably anxiety, depression is what you want to measure. Um because PTSD, you tend to get other problems with it. So, uh I said only 1% of patients with PTSD didn't measure positive for anxiety depression. Um And lastly, just to broaden it out slightly, these were the other aspects that that hatch and the group looked at. Um So as it'll be no surprise to you or anything to the right of the line shows increased mortality. Um and anything to the left of the line has reduced mortality. So, um age and male sex were uh predictors of mortality in the first two years after IC as was depression, which is the 12, 3/4 1 down. Um whereas things like anxiety and ptsd didn't correlate with mortality and you may or may not find interested in that Apache two did not correlate with two year mortality. But bearing in mind, these are people who have already survived and the purpose of Apache is not to look at two year mortality. It's more the ICU mortality. So um the physiology seemed not to affect the two year mortality, but certainly um depression's age and male sex did. So that's just one of the papers on um mental health outcome. So if we look at the the final domain for the patient group, then if we look at sort of cognitive dysfunction, um the brain ICU study, the reason I chose this was was their methodology is probably one of the most robust and their numbers that are really impressive. So um this group, the um screened patients, so to be included in the study. So kind of prospective recruitment from ICU. So really robust methodology, screening for any um sign of cognitive dysfunction beforehand based on a family discussion um and looking at the past medical history. So they only included patients who they thought didn't have preexisting cognitive impairment. Um They got 800/800 patients recruited delirium uh 74% which yeah, in my experience, it's probably at least 74% maybe higher with a medium of four days. Um Their follow up numbers are impressive. So almost 80% of the survivors at um three months and 75% at 12 months with a median age of 61. So this study um used two fairly comprehensive uh measures of, of cognitive dysfunction and it's all based on how many standard deviations you are from normal. So, traumatic brain injury is 1.5 standard deviations away from normal and school Alzheimer's which only applies to the over 65. So, um that's a subgroup analysis, I guess would be two standard deviations below um on the scoring system below for age and sex corrected. So, based on that, 40% of patients had um criteria would meet traumatic brain injury. So 1.5 standard deviations below and at 12 months, 34% of everybody would meet that criteria and 26% of over 60 fives would meet the criteria for Alzheimer's which at, at 20 at three months and it didn't really change much. It was still about a quarter, 24% at one year. So, I mean, that's a quarter of the over 65 year olds who, um, we believe didn't have cognitive impairment before the study, after IC would meet the criteria for Alzheimer's disease on these surveys. So, to me, that is quite striking, that's quite large numbers. Um, and this is what it looks like if you, if you plot it as a sort of dot wh skirt or box plot. So the thick black line in the middle of the box is the median, the box, the top of the box, the square box is the um upper interquartile range. So, um if you just focus in on those two, you can see the one standard deviation would be the colored sort of greeny turquoise b. Um and 50% at least 50% in each age group would not um score that highly. Um In fact, we close to 75% would get worse scores than one standard deviation, which you could consider as mild cognitive impairment. Um And then the traumatic brain injury line, we're looking at at least a quarter even in each subgroup. So at each stage, so even the um under, under fifties, um 25% of them would be the 1.5 standard deviations away. So they seem to identify quite a serious and long lasting problem and probably offers the best insight into um new cognitive impairment after intensive care and they also looked at various risk factors because again, I'm aware that not everybody will meet patients after ICU or want to be involved in a follow up clinic may not have the time or, or whoever to do that. But what can we do in ICU? So the strongest signal we got for cognitive dysfunction after intensive care for the events that happened in the ICU was the duration of delirium. Uh These are just two different measurements. They use the, our band and the trails be executive function. So, um yeah, the, the, the delirium was pretty consistent at every time point. And on both surveys with significant statistical significance, um duration of sedation coma didn't seem er relevant. Benzodiazepines maybe a mixed picture. Um although basically they didn't use very many Benzodiazepines. So their percentiles there 75th percentile, there was only 7.8 mg of benzodiazepine. So, um it's not the numbers for that weren't huge. So I'm not sure about that. But uh and again, the opiates, er, they obviously used lots of opiates with 1200 mgs is the fifth percentile. Um And we're maybe getting a signal across somewhere but it, it's not reliable, it's not robust and really, it's just that delirium probably does have an impact on cognitive function after IC, which might seem obvious, but it's good to see it written down and measured in a robust fashion. Um, the family or caregiver outcomes, I won't go into too much detail. This is just one literature review looking at the rates. Um and on the right hand side there, you can see the anxiety rates, depression rates and PTSD um at 12 months are, are still significant. So uh 15 to 2423 to 44% or 32 to 80%. So um definitely we're getting numbers in the range of numbers higher than the general population. And the PTSD actually is quite significant. Um But on the left, they kind of accumulated or looked at the other outcomes. So um work is a big issue for family members of patients who have been through ICU and we often call them the caregivers, which I think is a fine term. But the flip side of that is a lot of our ICU patients might be the caregivers for their family members. So they can be a flip of the role. Um And lots of things can change in your life afterwards. Um Health related quality life, use of medication and lifestyle interference. Um Everything is affect, can be affected by ICU. Um And I guess the last thing to mention is that employment one. So if we look at kind of overarching thing, so, II think one of the missing things from the definition is probably socioeconomic problems so that financial or um social burden that happens after I see you, the loneliness, whatever you, whatever word you want to attach to it. But certainly there's an effect on your social life, social um outcomes and economic and financial issues. And um it's something like 50% of all bankruptcy claims in the States site healthcare um or cost of healthcare is one of the reasons behind it. So this systematic review by involving Joe mcpeak and Tara Qus. Um So 56% of ICU patients did not return to work one year after ICU. And that's only patients who were in work beforehand. 1/5 of relatives left employment. Um And the burden of informal care is huge, at least, um 1/5. But um well, over a half, possibly as high as that. Um So I think this is kind of almost the umbrella thing I've called it the fifth domain. Um because I think that's the overarching thing that just weaves it, it's thread through absolutely everything in this sort of recovery journey for patients and their caregivers after ICU. And that's probably where we sort of inspire, maybe philosophy or thoughts come in. Um So that's we covered sort of the definitions. What is it? Um some of the evidence on the extent of the problems, uh breaking it down into each domain, just picking out a few papers, not necessarily covering everything, but, but just a few highlights there. So I thought I'd go on to chat about Inspire now. So, um before I chat about the outcomes, um well, you can read more about the Inspire project and er, this is, er, the paper we had published um looking at patient outcomes and I'll go through the results of this. Um but just to give you a bit of background. So inspire was initially set up at Glasgow Royal, er, about 2014 and then the team there T and Joe got a kind of grant from the health foundation and managed to expand it. So involved four health boards, five hospitals and we had to cross out Victoria uh Gri at Glasgow. Um and then Lanarkshire um was a joint clinic. So it was a kind of test of concept. Could two hospitals run one inspire, follow up program together. So, five hospitals for health boards and that was rolled out between 2016 and basically till COVID hit, um they're still running but the study period ran was stopped due to due to COVID. Um So what is Inspire? Well, this is our conceptual diagram. So, so inspire. Basically, if you think about all the different domains of post intensive care syndrome, we've mentioned including that socioeconomic stuff. It brings in many elements of the traditional follow up clinic. So you've got, er ICU doctors, ICU nurses, um physiotherapists um often think of the original sort of IC follow up clinic as a, a physio and a doctor and a nurse. Um But if you read the literature, actually, probably most of it was nurse L and then, er, with the physio input and occasionally a doctor. Um but we bring all of those people together, including the pharmacist because the medication problems after ICU can be huge and then other kind of less traditional elements. So financial and welfare advice, um patients get a chance to visit the ICU. Uh there's a psychologist at every clinic. Um and um we kind of debrief the critical illness and alongside that patients are brought to inspire in groups and also their caregivers, relatives are invited. We don't limit it to just one caregiver. Um if a couple of people want to attend and that's fine. Um And there's a lot of downtime in it which builds in a lot of peer support and we try and set goals for people or preferably get them, set their own goals and see how they go and we try and make links with the community and we try and think about that sort of returning to work or um occupational and vocational rehab. So that's kind of conceptual thing. That's just higher level. What does it do? This is a kind of more practical kind of um breakdown of it. So it doesn't need to be five weeks long. But when I was involved in studying it, it was a five week program. But um it could be adapted locally to be four weeks, 56 or three, whoever works. Um But basically a group of patients and their caregivers are relatives. We've invited along to the program. And there might be five half days. Um, so they would come, they would come together, there would be coffee tea available a bit of downtime, a chance for the patients, relatives, caregivers, family members to all interact and mingle. Um, during the first few weeks they'll each receive a 1 to 1 review with a pharmacist, physiotherapist and doctor nurse. The pharmacist is really important and we've published some stuff on that. Um, yeah, it's not uncommon. You might see some cloNIDine, the patient was on for delirium still on six months later. Um, and cardiac medications are absolutely huge. The aspirin that should continue or was stopped and shouldn't have stopped or there is a huge amount of pharmacy stuff. Um, and it also feeds backwards. Our ICUs learn from this, but they also receive a 1 to 1 review by the pharmacist. Physiotherapist wouldn't necessarily be an exercise class or anything like that. Um, the, yeah, they did start off a lot of the early clinics, had exercise classes and group therapies, but I think most of the centers who run it now are. It's more a 1 to 1 chat about how the patient is, what their physical goals are and referring them on to community, a gym or physio review or whatever. Um, seems to be the main focus. It's more about chatting with the patient and kind of working out what they need and then getting them involved in community physio, um, as required the doctor, nurse will all be brief of what happened in ICA. Lot of patients just they really don't know. Um for patients say I have no idea I had sepsis doctor or things that we thought were really obvious. Um So just a debrief of what happened, which helps put a lot of things into context. Um for the patient, we'll also then have a look at them and look at any unmet medical need. And again, a lot of referral on perhaps or referral back to their gp ideally, we would empower them to take control and ownership of their own health. Um but signpost them and help them sort of navigate the healthcare system. So can I offer them some education from that point of view? But that's very much what will be discussed in that session, be very patient dependent, but the debrief and then we also give them a letter which summarizes in lay terms, what happened in ICU and what they went through within each week, we'll have a, a um sort of group education sessions. So we might have pacing of activities which in paisley is delivered by the physios. Uh the chat about just building up exercise over time rather than just hammering it hard and doing nothing for a week or a month and a group psychology session. So this would ideally be delivered in two sessions, you would separate out the patients and the caregivers and you would get a psychology session for each one which might be involve a little presentation. And then I came a discussion. It, even if the psychology session occurs in week four, we're into the weeds in the depths of chatting about the we and memories and strange dreams and being on a boat and the aliens come in. Um, and people just, um, patients who at 10 in by quite often just are desperate to chat about this and work out. Was this normal? Um, and that's a huge part of it. So psychology is delivered as a group session. But I mean, I think we start covering it from the moment the patient arrives. Um, and then a sleep session which in Paisley is delivered by the pharmacist. But, um, it could have a different slant depending on local need, um, dietetics that can either be referral in or a session on that. Um, and then occupational and vocational rehab. So citizens advice is huge. So we get them along to chat about financial services, how to get help filling out forms, whether it's their, their pet form or whatever. Um, or whether, um, it's about returning to work or a change to their, their lifestyle and how that'll affect them financially. And a lot of it's just letting them know what's out there and letting them know what, where they can get help for things. Um, and I guess the last thing is the peer support. So that's the arrow. It just, that just keeps going week in week out, um, for, for the cohort that lasts for five weeks. Um And hopefully the group build up a rapport and, and certainly it's not uncommon to have patients exchanging phone numbers of e-mails with each other. Um Most recently we had two patients, two women who had stomas and they, they were in touch with each other for support with that. Um, and then volunteers. So, um that could either just be a volunteer or it could be a previous patient who's been in a previous cohort and comes back to help us maybe make some coffee, mingle with patients and kind of get the chat going. So um that can all just happens as the thing runs along continuously. So that's kind of a rough overview, hopefully makes sense how the uh program would work um over, over a five week period. And as I said, it doesn't have to be five weeks, but for the purposes of the study period, it was, they were all five week programs. Um So that's inspired, that's what we do and that's where it's delivered um to try and put some numerical data on this. So, um we, we didn't run a randomized clinical trial because we were trying to upscale things. Our funding from the Health Foundation was about feasibility and expanding the program and seeing how, how reproducible it was in other areas and, and Aberdeen uh la lot in that but we thought it'd be good to get some one year outcomes and look at actual sort of more objective measures. So, um we had the Inspire groups that were running where I've already mentioned Gri Cross House Victoria Monklands and Wish. And then um on top of this, we added a postal survey on. So um the key was to survey hospitals that didn't have any ICU follow up because I think that's the issue is obviously there's, there's been fantastic sort of explosion and, and, and post ICU care and, and people's interest in it, but um we wanted as few confound as possible. So um at that time, the Q the Reh Inverclyde and her meers were, were um accessible and we could collect data from them quite readily and they did not have um any follow up in place for their ICU patients. There are also about 15 patients we've surveyed before. Inspire was set up in each of the four main sites that were being added on top of the royal, the Glasgow Royal. So um we had a few kind of, they were contemporaneous with the gri cohorts, but um they kind of were historical to the, the Cross Victoria Monklands ones. But um that all went into the mix and that was a postal survey. So certainly methodologically there's a difference in each cohort. But um uh it was a good way to collect data in a very pragmatic way to get that information, what we measured was EQ five D. So that sort of overall health and health problems, hospital anxiety and depression scale. Um We measured self efficacy. So the score ranges from 10 to 40 on that. Um And it's about how you could um solve problems. Basically, many of the questions are, if this happened, would you be able to come up with a solution or what would you do? And it's about, does the person have the ability to deal with things that arise in life basically? And, and part of that was conceptually was this Inspire program, was having a longer lasting effect rather than just a snapshot of, right, we'll fix your problems and then you leave us after five weeks and then you develop new problems as time goes on. Could we educate you on how to engage with the system, whether it's healthcare or general society? And, and actually, when new problems arrive, would you have new skills in your toolbox to be able to deal with them? And that's part of what the self efficacy survey was about. And then pain knowing that pain is an absolutely huge problem after um after ICU or well knowing, it probably was a problem and when chatting to the patient. So when the inspired groups were set up, they were set up with focus groups very much directed by patients and relatives and what they wanted. Um And pain was a recurring theme. So we, we added in a, a brief pain inventory which is complex survey and difficult to interpret, but it, it certainly offers a lot of insights and information. Um So obviously, this was a randomized trial um and the cohorts could be prone to differences. So, um I think follow up from the intervention of the Inspire Group was pretty good. Uh uh Two thirds um from those consented that initial Inspire visit, we managed to get one year. It comes on which I think is reasonable as you can see. Well, you might not see for might be absolutely tiny there, but we had 570 going in invited to Inspire. Um 253. So 50% of those invited turned up to inspire. Um and then we consented the majority of them about 80%. And then we followed up two thirds and the post survey, there aren't as many steps. So, um we'd like 450 odd uh percent surveys and we got about a quarter back. Um which for that type of study, a postal survey isn't uncommon and we sent them reminders. So we did our best to get people if we could. Uh And if they phoned us, we would do it over the phone and things, but we didn't have and the ethics a phone call with them, for example. So it was just the postal survey. Um So this would be your table one, a lot of numbers there. Um, I wouldn't worry too much about it but I guess just, uh, if it was a randomized clinical trial then p values would be against the law in a table one we shouldn't do that. But for this sort of study, um, I think it's relevant and it's important to know where the different parts are. Um, age almost reached statistical significance. I don't think the age sort of range difference, I don't think stands out to be absolutely huge. The lower end of 50 upper end of either side of 70 for interquartile ranges, um admitting specialty was different and that was just baked in because each hospital has its own blend of medical and surgical admission. So I'm not sure we would get away from that. And again, that's reflected in the numbers that had an operation length of stay was different. Inspire cohort and a far longer ICU and hospital length of stays. Um I think it's part of just we're offering an intervention and those that were in ICU longer were more likely to turn up or maybe have a relationship with the ICU. So I think there's some selection to those who were in ICU much longer in the intervention. Cohort and then time to follow up is just a bit skewed. Um II, the actual numerical values, I think just there were some outliers. So there were some patients that um came to inspire after a very long time, which I think is part of, um, after a very long time post hospital discharge. Do you think it's part of the nature of setting up a new service and you want to get people in? And, and that's kind of what happened. We did kind of have rough um inclusion criteria. Anyone ventilated, anyone who was level two for a week or more was a kind of a rough um criteria. Um And, and we certainly stuck to that, but obviously, that's quite broad. Um The absolute median values though were about 15 months follow up was completed, post hospital discharge. Um So to correct for some of these confounder, we ran a regression model and included those things there. Um We had the numbers to over 250 patients. So 100 and 15 and one go are 100 and 37 in the other. So we could run it with, with 1010 areas included in our regression model. Um And this was our headline result. So health utility score. So that's the overall health um as determined by the EQ five D. Um It's a pretty strange number but the Inspire group er improve were 0.12 higher. And the scale on this is 0 to 1 where zero is er death and one is uh the best health possible. It does go negative because there are survival states that are considered worse than death. And every country has a different med on that. So um for the UK, it's about minus 0.5. Um So we improved things by 0.12. Um which and the whole scale ends up being about 7.5%. It was statistically significant. Um And perhaps most importantly, the sort of minimum, clinically important difference for this survey is really well documented is 0.08 and II think it's fair to say we, we breached that minimum threshold. So, so um I think this definitely is a signal that attendance Inspire was correlated with um quite a robust um outcome of an improvement in health related quality of life of of 7.5% or 0.12 on that scale. Um The EQ vas is much simpler to understand 0 to 100. Uh The patient just scores. How's your health today? And there was a 12% improvement that was statistically significant uh and the generalized self efficacy. So that's the, the one I mentioned where patients can solve problems and deal with things. Um It was statistically significant. Um And the minimum clinically important difference for that isn't as well defined, but 2.32 points on a 40 point scale um seem seem reasonable um hospital anxiety and depression. So this was a logistic regression. So these are odds ratios. So um there was a 62% reduction or lower rates of um of depression sorry in the er Inspire group and that was statistically significant. Uh As you can see by the the spines on the right hand side and anxiety didn't achieve significance. Um So there was no big difference in an anxiety in each group. Um Pain. So I mean, just ignore the thing on the right hand side. There. Basically, there was no strong signal of benefit for pain in the Inspire group where we get a few things over the line. So things like pain, interference with enjoyment of life. But if I was saying that that's what the Inspired Clinic or program achieved, then I would definitely be over selling that to you. So um the big thing or the most striking thing was almost 60% of our patients said that they would experience pain in the last week. That's worse than every day aches and pains or kind of normal type pain. So um that sounds like quite a high number. Um that held true in the medical group and the surgical groups, it wasn't all kind of chronic pain from wounds. Um And that's much higher than the general population. So I think it's about 15% the government say the chronic pain rates in the UK. Um But also if you just ask people randomly and if you take a selection of society, about 30% maybe 35 would answer yes to that question. So we're, we're looking at double the pain in the general population. Um And this is all everybody, whether they went to inspire or not. So, pain seems to be a problem. Inspire is not a pain management program. And I don't think we had a consistent signal of benefit or, um, we didn't have inspire, correlating with improved outcomes in terms of pain afterwards. Um, but it's certainly something that, um, merits more attention in the future. Um, we then went on to do some more, er, stat stuff just to see if things he held true. So we basically mocked up uh uh how we'd inspire Luke if we ran it as a randomized controlled trial and we did a propensity match score. So we had 75 in each group. Um and there um baseline demographics all matched perfectly and we reran the models and we effectively got the same answer. So, um we had the same outcome for health utility, visual analog scale self efficacy and depression and all seemed to inspire was correlated. Um When we basically effectively using a propensity score matching technique, we removed the patients that were very different in each group. Um So it held up to this sort of sensitivity analysis. Um And lastly on, on the patient outcomes, uh this is just the kind of um dot Whisker plot. So the thick line is the median looking at um outcomes for the unadjusted group which uh are on the left hand side. So before matching and then just straight up uh standard testing. So no regression models and no connection. So um our health utility score didn't quite hold up to that sensitivity analysis um with the P value of 0.14 in the matching process, the visual analog scale, you can see that difference from space. So we're statistically significant even just in the raw groups that are both very different with longer lengths of stay in one. And, and a few differences in their medical or surgical diagnoses. So it holds true no matter what we do to it. And the generalized self efficacy, again, it holds true on the matching group. But straight up testing before we do anything, it didn't hold true. Um And uh the, again, the depression held true on the matching group. So I think overall, um we're still seeing that a consistent signal of benefit or uh to put it more precisely inspired being correlated with better outcomes. Uh and uh overall health related quality of life, self efficacy and depression. Um And this is just to show you the outcomes just if you think back to the earliest slide I showed you basically, 75% of our patients had a problem in any domain of the EQ five D. So if you could ask if you asked a group of ICU patients do have problems, usual activities, anxiety, depression, pain and discomfort, mobility or self care, 75% we'll see they do have problems in those areas. Um That was also, I was trying to sort of work out where does inspire work. If there is any signal of benefit, it's probably in pushing patients down this. So rather than getting rid of all their problems, it maybe modifies it from moderate problems to, to less severe problems or severe problems to just mild problems. But um there was no clear signal of one area that inspired helps more than the other. It seems to be a global problem. What also stands out is all of those sort of spider diagrams or target plots or um, radar plots are all very symmetrical. So patients seem to have a global problem across the board and it won't be the same problem, but you can find roughly the same rate of problems in each area, whether it was the postal survey or the um, or the in person stuff. So, um, to me that was quite striking that there was quite consistent problems across these five areas. I see. And so that covers the sort of, er, sorry, I went into the weeds of the stats there and I hope that was ok for everybody. But, um, I think it's important for that kind of study. Um uh just a quick mention on the other aspect of things. So, caregiver outcomes. Um Basically we looked at um, the patients could identify their primary caregiver um or relative and uh we did some surveys on them as well. Er, and so this is one year outcomes. So just to show you there were some differences, the relationship was mostly the same between both groups. Obviously, not every patient had a caregiver. So we're looking at a slightly smaller cohort 89 and 81. Um And some of the differences that you'd seen in the patient paper, how true. Um So length of stay was slightly different. Um So we, we did some regression analysis on that as well, including these variables that were important and were different. Um And we, the surveys we did were just slightly different just because some of the patient stuff doesn't apply. So we did a hospital anxiety and depression scale carer strain and insomnia. Um So, if you remember the patient outcomes Inspire was correlated with a better outcome for depression. Whereas uh for the caregiver group Inspire was correlated with a better outcome for anxiety, which may show a slight difference in the sort of type of mental health problems that are experienced by either the patients or the caregivers. Um But that was a, so you're looking at a 58% reduction um and anxiety rates and the Inspire Group. Um We also looked at insomnia and there were lower rates of insomnia. Um And that was statistically significant um on an odds ratio. So, logistic regression and carer strain um again, was lower er correlated with lower rates in the Inspire cohort. Um So we seem to see some sort of benefit from Inspire. And we can't definitely say it's, it's all inspire. There's methodological um issues with this type of study, but it's probably the best we've got at this moment in time. Um And lastly, just to mention, it's not just the general ICU. So everything we did to this point was in a general ICU teaching hospital or district general, but we did look at a small group um from the golden jubilee. And so, II think my from this is cardiothoracic patients still experience problems that are similar to pics. Um The rates maybe for self care and mobility and things might be slightly lower. But the rates of anion, the same rates of pain and effect on you are all um are all pretty similar. And actually, um at one year, you could expect your, your ICU patients who've gone for a specialist service. Now, bearing in mind, these weren't just the six hours and were making weeding type patients. These were um those that had had complex length of stay. So I think their average uh their sort of median length of stay was six days in ICU. So these are the more complex ones. They certainly have, I consider fairly high rates of problems afterwards. And um like we go into a lot more detail, the qualitative assessment. So um certainly the anecdote and the discussion and the qualitative assessment was that um patients got a lot out of it and as did their caregivers they still had all the same problems of the uh muscle weakness and, and their pharmacology was certainly pretty complex afterwards because a lot of them have bleeding problems, but also have cardiac problems. So they're, they're frequently on not quite the right medications afterwards. So, um, basically, even in a specialist service, the need for something like inspire that complex case management alongside, uh all the other elements of inspire did seem to be beneficial and numerically, the patients seem to have similar problemss to the ones that we sought the general um inspire outcome. Uh And this just shows the sort of anxiety in the caregiver group compared to anxiety, depression in the caregiver and patient groups. So, um they tended to start pretty high at baseline and they seem to come on par with the patients afterwards, um which is something we've seen in other general groups, but mirrors kind of the, the problems they have afterwards in the general ICU population. So that's just a, a little tour of sort of cardiac stuff. It's smaller numbers. But um just to show that, yeah, it doesn't matter what IC you're in. I think if you start looking, start scratching the surface, you'll find your patients have issues. Um Inspire is, is one solution. It's one way of doing things. Um And certainly we've done our best to kind of numerically put some data on that. And yeah, the cardiac thing was just a wee extra on top So I think that's pretty much everything I want to talk about. So I've gone through the definition of post intensive care syndrome, gone through some of the common problems and rates of problems you might see. And a few of the papers that better define that, um, described the Inspire program and what it involves, er, and then, er, finally chatted about kind of my data and what we've been looking at as a group and our outcomes from the, the 12 month study looking at Inspire for patients and caregivers afterwards. Um So I think hopefully agree that Pixes seems to be a problem. Uh issues with health related quality of life are common after critical illness. And my impression is that Inspire did make a difference and I think that data supports that. Um of course, in a cohort study, er this wasn't randomized. We can only really say correlated rather than causa causation. But um II think it's still a fairly robust data and um yeah, it's not a randomized controlled trial. So I think that's probably main limitation and I think that's, that's me. Perfect. Thank you so much for that really comprehensive um uh overview of post intensive care syndrome and then a deep dive into the outcome data from, from the inspired cohort just while we're waiting for folk to type. Do you mind if I ask a question? Is that OK? I'm, I'm curious to know both from a data point of view, but also from a personal opinion point of view, you've also got a well established service that had to very quickly pivot during COVID to being delivered in a virtual set up. And I know from various post intensive care um sort of follow up set up throughout the UK. Some have chosen to go back to in person. Some have chosen to remain entirely virtual, given some of the advantages of that and some have chosen to take a bit of a hybrid approach. Is there any data that supports effectiveness of your approach? And then what's your personal opinion on that? Um So, II don't think there's a lot of data that supports one approach or the other. Um I guess the COVID group would in some ways feel like a very specific group. So and also like I stopped, like we stopped the um postal survey, we would have continued that a wee bit longer, but we felt if there was a pandemic, everyone's mental health went down a little bit. So it's hard to compare one with the other. So I'm not sure that we were ever likely to have that data um in terms of what people do. So I guess what we've done at Paisley is we just let the patients choose and we say you can come in person or you can come online, it's up to you and probably over 90% choose to come in person, but no other clinics that maybe a slightly different blend from that. Um I guess the closest thing to some data is there are some studies out there that have looked at health technology and, and kind of looked at an app to help guide people in and kind of an online psychology session. I think it was one of the ones I can think of particularly and it didn't show any benefit to any outcome measures and it was narrow and very specific in what it was measuring. So and what it was delivering as well. So it wasn't as holistic or comprehensive. So um I can see why it might struggle to get over the line. But so I think the best bet is probably um you should probably offer it to the patients and it should be patient driven. And so whether that's a focus group or whether you just make, ask the people to talk with their feet and say, what would you like? Um I think the peer support is difficult online. So that's the ICU steps people and, and um other places that do stuff like that, the um a lot of tried to go back to in person just because the it happens a lot, kinda basically you gel a lot more quickly in real life and it takes a while for an online peer support group to build up. So there's a few questions coming through. So K and a question from Kevin Rain here saying Oh, sorry, I lost that question. Have you considered in a pain specialist as part of the, into your kind of team or is there? And is there an investment on return from Inspire if that was to be done, do you think? Yeah. Yeah. Oh, interesting one from Kevin. Thanks, my CD. Um So pain, we haven't embedded pain specialist and inspire. Currently, Joe mcpeak and an MD student are looking at pain specifically looking for biomarkers of pain. I think we're still at early doors with that. I think the main thing is to um refer on appropriately and screen patients. Um and what we still do and um is we do a three month follow up. So patients are seen hopefully within four months and then they will be followed up within uh three months after that. So it'll be beyond six months. So they will be in the zone of chronic pain and probably a good time to refer on to pain. Um And as a return on investment from Inspire, it's pretty hard to, to define that. So certainly a lot of our populations weren't in work beforehand. So it depends on what return you want to talk about. So if you look at things like um hospital readmission, I guess might be a good one and we've looked at that and actually it probably doesn't help with that because it makes patients too, too far down the lane. So if you want to stop people coming back into hospital, you probably need to get in touch with them a day or two after hospital discharge. Um, and then returning back to work, you need a huge cohort to say, well, did we do that? I don't think we've got the numbers to support that, but, um, we've certainly got the patient outcomes. Uh, it helps them in terms of service improvement and that value for EQ five D that 0.08 the magic number that includes some health economic assessments. So that's actually slightly built into the tool anyway. So, um that's probably the best we've got at the moment. Um Katie Percival was asking hello and she'd like to ask, did you notice a difference in socioeconomic status in your post ICU patients who did and did not enroll? I know we didn't really, didn't really break down your kind of didn't decline the invitation group. Um I'm wondering if the five week program of full afternoons may have posed a barrier to some of those patients. Um Yes, potentially. So what I can say is we basically, we didn't have because it was being run at each site and each site was inviting patients. We didn't have good robust data on who exactly they invited. All we had was good data and who turned up and who was consented. So, the truth is, I don't know, I guess I had SI MD there and we had a good spread across the five socio economic bands. Um And both were similar between the postal survey and the um, and the in person one. So if the barrier was time commitment, then um actually the postal survey was there and people could fill it out and you could argue that perhaps we're more likely to get the more kind of affluent areas, people filling out and send it off, but maybe don't have the time to come to inspire. So, um we don't have the numbers for that, but we do have um a decent spread across the, the five quintiles. Um Martha mcdougall is see a very interesting, great results. Thanks for your talk. Um I wondered if you'd ever thought about including spiritual care teams such as chaplains in the program, um as part of holistic care as for the Scottish government. Um, so I haven't until recently, we've got a new chaplain A H and, and I have wondered if, if she would want to be involved, but um the, it wasn't part of the initial set up and it didn't appear in the focus groups for Inspire. So it wasn't part of the discussion in terms of patients weren't asking for that and neither were caregivers, but I think Inspire is a flexible platform. And I would encourage anybody to look at these elements and look at what your local um population needs and improve and kind of add these things on if required. Um And I think it's a good point. And then finally, are there plans to expand, inspire uh across the rest of Scotland or elsewhere in the UK? Uh That's up to those areas. So we, we the Health foundation and the money for that is kind of that project has ended. Um And the areas that were taken. So we had the Victoria. So there was some representation from the East and Fife. Um but uh it's really locally, it now needs to be delivered. So, so each site now is funding it from their own ICU budgets or their own hospital budgets or trying to build it into some sort of um health and social care partnership. Um So, like, I think any inspired team would be happy to help out if people were keen to look at this sort of thing and setting it up. Um And uh yeah, I guess that's where they're publishing the data and the information is to empower people to be able to put business cases together and put things forward to their own local teams. Perfect. I can't see any other questions. We'll just maybe wait another 30 seconds or so to see if any other pop up. But um what I'm gonna do just uh just now is pop uh uh a link to the feedback form for this evening uh into the chat. And if you follow that link, you'll be able to fill in some feedback and then you'll be generated your CPT certificate for attending and we uh you'd be glad to know there's, you'll all be able to pop an hour of RCO CPD down for this. Um uh And I can't see other, any other questions. So, uh thank you very much, Doctor Henderson for giving up your time. Um, to talk to. It was really nice to, I think, see a lot of multidisciplinary attendance at this uh at this meeting and people who are really engaged in ICU follow up. Um The next uh six evening um uh education update is on the 20th of April. Um and Dr Gregory mcneal from the Royal Infirmary of Edinburgh will be talking to us about all things deteriorating, patient and IC outreach, which I know is a bit of a controversial topic in Scotland. Uh Thank you all and hope to see you soon. Ok. Thanks for having me. Cheers all the best. The