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Hi, good, good evening, everybody. Welcome to this uh six evening education update. Uh We are delighted this evening to welcome Doctor Philip Henderson along to talk about post intensive care syndrome and the Inspire cohort if you'll indulge me less, but I know many of you will be members of the Scottish Intensive Care Society, but just a plug. Um The Scottish Intensive Care Society is designed to coordinate and represent the specialty of ICM in Scotland. And really the the activities focus on education, research and audit. And there are various categories of membership for all different kinds of healthcare nationals and their number of benefits of membership including a reduced rate at meetings, comprehensive transfer insurance. Um And if you're, if you're interested, they will, they will soon be education and travel bursaries um 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 anaesthetics, the Rh in Paisley. Uh He runs the inspire follow up program there which has been on the goal for some time for four years. Now. 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 Tarka seen Joe mcpeak in Martin Shaw help to guide him through that endeavor with help from the Health Foundation in the University of Glasgow. His interest at that point was around quality of life measures for patient's and caregivers. Uh One year after their critical state, critical care state in general and cardiothoracic ICU um that lead to some really impactful research output. Um And he also got the opportunity to supervise some excellent undergraduates and critical care related projects. Um If he isn't working, you'll find him uphill either in walking boots or on skis. So, thank you so much, Doctor Henson for joining us, a member that further jail. I'll hand over to you. Okay. Thanks Jelly. Um So, yep, everyone should be able to hear me okay and see my slides. So I was just going to go through um some aspects of post intensive care and inspire projects. So basically three sections, hopefully get through it in about 50 55 minutes and we'll chat about post intensive care syndrome and what it is and some of the background to that and where, where the kind of evidence has gone, got to chat about the Inspire program and what that involves and what we did there. And then look at the outcomes of the studies that Jelly mentioned, I looked at. So basically, looking at the one year outcomes and groups of patient's 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 regular and 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 we restore an 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? 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 a Critical Care Medicine in the States. So they convened a meeting and 2010 and they basically coined this concept of post intensive care syndrome up to that 20100.2010 people have done lots of research in it. If people like Margaret Herridge, Herridge will go into 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. 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 achieved their goals with that. So over the sort of next decade from 2010 to 2020 there was a 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 achieved their goals admirably since then, the society credit care medicine have actually pushed things on beyond that. So we don't quite have a court outcome set, 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 the same sort of group met up with a few new members 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 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 and new or worsening problems in mental health. These would be problems arise after critical illness, um or, or noticed after critical illness and they persist beyond acute hospitalization. So patient's who are home or in another healthcare facility, but they've left the hospital, they have 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 picks would be relating to the survivor and that's what we're talking about with the mental health, cognitive impairments or physical impairments. And picks f would be um the picks in the family member. So that's primarily related to mental health problems. Although, and the the range of issues that family members can have as huge afterwards as well. And about 2017, there was a pediatric picks that was also defined, but I've not looked at that much and I focused very much on the picks and picks f But as you 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, visual, spatial and physical impairments. Um which actually been one of the hardest things to define or look at in terms of primary function, neuro, muscular, physical function. But we're probably moving towards a more global measure for physical impairments, but that's how you would define it. Those would be the sort of main domains, post intensive care syndrome. And so that was original sort of 2010 definition that that was published in 2012, in 2019, the same sort of group met up. 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 him measuring whatever they could, um things have been tightened up. So it's not quite a court outcome set of that. These aren't the things we have to measure afterwards. But if you wanted to go looking for these problems, this is probably the areas you'd look at. So and the Montreal cognitive assessment tool, the mocha hospital anxiety and depression scale for post traumatic stress, the recommend impacted events scale. There are two different versions that are of 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 primary 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's not a very patient centered outcome, but it's kind of, it feels a little bit more objective granted it's dependent on the patient, putting an 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 you're a call. So the E Q five D is probably one that's been repeated many times and it's quite robust and that's got five main areas. It's basically a survey looking at patient's um limitations and mobility, selfcare, your usual activities, pain or anxiety and depression. 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 society of critical care medicine have been on. Um 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. They've also been suggested risk factors because obviously, um we're all, we're all working 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 to determine of that is pre existing cognitive dysfunction. You're more likely to have worse cognitive function afterwards. If you had a problem beforehand, delirium is a huge issue. And I'll show you a paper later on that looks at cognitive function related to delirium sedation and perhaps benzos and then other markers of, of 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 pre existing 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 there may be more at risk of having no term as in the born three months, um problems. And if they have early anxiety, depression ptsd, then more likely to have the long term sequela of that. Um, notice the massive gaping hole 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's so broad but be can be so focused as well. So, and you might be limited by your cardiovascular health. You might be limited by your loss of skeletal muscle mass and your frailty and, or you might have a RBS and along sequela 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 I see you for that. But beforehand, going in the worst, your functional physical health is the more frail you are and interestingly cognitive impairment and 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 affect these long term outcomes. So I thought I would take you through a few interesting papers, not necessarily covering everything, but just a few of the either the main names or those that are significant in terms of numbers or methodology. So if you look at the physical outcomes, so this is Margaret Herridge. So her group, the Canadian intensive ist who um started a lot of this and a lot of hard work started in the early noughties before there even was the term post intensive care syndrome. She generally looked at the group generally looked at ARDS. 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 for a lot of the group stuff, we're was focused on the physical outcomes. So, and as you can see here, so we've got this sort of Kaplan meier type at the top and survival, but next down. 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 the zero and these are only survivors and they will continue to improve physically for quite some time. But then we'll hit a plateau and that will happen round about the 18 months, two year mark and the plateau is generally less so 70 blue, 75% of the predicted value and, 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 S F 36. It's just another survey. Don't worry about its name, but and the physical components 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 patient's then reach about the one standard deviation level by the two year mark and then seem to plateau out after their. 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 are you functionally? I've not shown you, they did a whole battery of other tests in this study. So this is five years follow up. It was written in or published in 2011. Um They did other things. So things like pulmonary function, even in ARDS, it generally normalizes and, and certainly there might be a few outliers who have persistent abnormalities in their primary function. But on the whole patient's recover and those sort of objective numerical measures get better and don't seem to be a lasting problem. But despite that patient's still have a lasting problem and either things you survey them in or when measuring a six minute walk test. So we can't tie this together with ARDS causing a severe respiratory problem. And there's definitely a lot more to it than that. Um And co morbidity 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 co morbidities, 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 and, and maybe highlights some of those risk factors that if you get pre existing 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 that things can get a lot worse and they take a long time to recover. But you obviously where you start from, your baseline is very important as well. And also alongside that, it's a target where we can focus things and say, look, there are groups of patient's that after I see you and have huge expenditure. And somewhere like North America is pretty good for measuring this sort of thing because of the healthcare 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 and and respiratory function is not going to give us all the answers, I guess is the summary there moving on to hit 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 patient's were surveyed from the economic data, England and Wales. And that there are you poke loads of method illogical flaws in this paper. But actually the numbers hold true when you look at small studies that actually look at the outcomes. They get similar results basically. And so this one is notable just because it's absolute size, the 5000 patient's post icu um So anxiety rates over the first year where 46% depression, 40% and PTSD, 22% anxiety, depression was measured using Hades the hospital anxiety and depression scale just as a reference range. So, and the UK government would, when they survey pay, they do random surveys on the general population, they would say mental health disorders occurring 15.7%. They get their own survey that's similar to Hades but isn't exactly had and then had depending what survey you read a study, you could get positive uh 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 graphs on the right hand side, they just split them up into different categories. Green is no a mental health problem. Yellow is mild, orange 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 and that we would use when measuring using hospital anxiety and depression scale. And the bottom one is PTSD. So rates of 16 18% depend whether you measure things at three or 12 months. And so mental health problems are common after I see. Uh I see you and they also have a other impact. So this study looked at mortality in the two years after I see you and they looked for associations to that. And the strongest association they got was those who scored positive for depression on the had score were 47% more likely to die in the first two years. And that was statistically significant with the confidence in flu's not crossing. Um And also of interest was basically PTSD does not occur in 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 depression or anxiety. But, and if you were going to be sort of pragmatic and measure the minimum things you can then probably anxiety, depressions what you want to measure because PTSD, you tend to get other problems with it. So uh there's only 1% of patient's with PTSD, didn't measure positive anxiety, depression and, and lastly, just to broaden it out slightly, these with other aspects that that hatch and the group looked at. So as it will be no surprise to you or anything to the right of the line shows increased mortality and, and anything to the left of the line has reduced mortality So age and male sex where uh predictors of mortality in the first two years after I see you as was depression, which is the 1 to 3/4 1 down. And whereas things like anxiety and ptsd didn't correlate with mortality and you may or may not find interested in that Apache to did not correlate with two year mortality. But bearing in mind, these are people who've already survived in the purpose of Apache is not to look at two year mortality. It's more the ICU mortality. So um the physiology seem not to affect the two year mortality, but certainly depression's age and male sex did. So that's just one of the papers on mental health outcomes. So if we look at the the final domain for the patient group, then if we look at sort of cognitive dysfunction and the brain, I see you 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 screened patient, so to be included in the study. So kind of prospective recruitment from ICU. So really robust methodology screening for any sign of cognitive dysfunction beforehand based on a family discussion. Um and looking at the past medical history, so they only included patient's who they thought didn't have pre existing cognitive impairment. Um They've got 800 over 800 patient's recruited delirium uh 74% which yet in my experience, it's probably at least 74% may be higher with a medium of four days and their follow up numbers are impressive. So almost 80% of the survivors at three months and 75% of 12 months with a median age of 61. So this study in used to fairly comprehensive uh measures of, of cognitive dysfunction and it's all based on how many standard deviations 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 on the scoring system below for age and sex corrected. So, based on that 40% of patient's had, um, criteria would meet traumatic brain injuries, 1.5 standard deviations below. And at 12 months, 34% of everybody would meet that criteria and 26% of the over 60 fives would meet the criteria for Alzheimer's which it's 23 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 old to, um, we believe didn't have cognitive impairment before the study. After I see you 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 doc Whisker or box plots. 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 upper interc Wartelle range. So um if you just focus on in those two, you can see the one standard deviation would be the colored sort of green, a turquoise box and 50% at least 50% in each age group would not score that highly. And in fact, we're close to 75% would get worse scores than one standard deviation, which you could consider as mild cognitive impairment. And, 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 under 50 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 called new cognitive impairment after intensive care. And they also looked at various risk factors because again, I'm aware that not everybody, we'll meet patients' after I see you or want to be involved in a follow up clinic may not all the time or, or whatever to do that. But what can we do in ICU? So the strongest signal they got for cognitive dysfunction after intensive care for events that happen in ICU was the duration of delirium. Uh These are just two different measurements. They used the are bands and the trails be executive function. So, um yeah, the the the delirium was pretty consistent every time point and on both surveys with significant statistical significance, um duration of sedation coma didn't seem relevant. Benzodiazepines maybe a mixed picture. Although basically they didn't use very many bends with Dyazide pains to their percentiles. There, there are 75th percentile where there's only 7.8 mg of benzodiazepine. So um it's not their numbers for that. We aren't huge. So I'm not sure about that. But, and again, the opiates, they obviously used lots of opiates with 1200 mg is the 75th percentile and, and we're maybe getting a signal across somewhere, but it's not reliable. It's not robust and really, it's just that delirium probably does have an impact on cognitive function after I see you, which it 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 and on the right hand side there, you can see the anxiety rates, depression rates and PTSD and 12 months are are still significant. So 15 to 24 23 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. And but on the left, they kind of accumulated or looked at the other outcomes. So, um work is a big issue for family members. Patient's who've been through, I see you and we often call them the caregivers, which I think is fine term. But the flip side of that is a lot of our ICU patient's might be the caregivers for their family members. So they can be a flip of the roll and lots of things can change in your life afterwards. And health way to quality life, use of medication and lifestyle interference and everything is affect can be affected by I see you. And I guess the last thing to mention is that employment one. So if we look at kind of overarching thing, so I think one of the missing things from the definition is probably a socio economic 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 outcomes and economic and financial issues. And um it's something like 50% of all bankruptcy claims in the states site healthcare cost of healthcare is one of the reasons behind it. So this systematic review by involving Joe mcpeak and Tara cuisine. Um So 56% of ICU patient's did not return to work one year after I see you. And that's only patient's who were in work before. And 1/5 of relatives left employment and, and the burden of informal care is huge at least fifth but well over a half, possibly as high as that. And 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 its its thread through absolutely everything in this sort of recovery journey for patient's and their caregivers after I see you. And that's probably where the sort of inspire maybe philosophy or thoughts come in. And so that's me covered sort of the definitions. What is it? Um some of the evidence on the extent of the problems 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 uh before I chat about the outcomes, well, you can read more about the Inspire project and this is the paper we had published and 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 with Glasgow Royal about 2014. And then the team there, Taran 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 Cross, how's Victoria uh G R I at Glasgow and, and then Lanarkshire um was a joint clinic. So it was a kind of test of concept could to hospitals run one inspire follow up program together. So five hospitals, four health boards and that was rolled out between 2016 and basically tell COVID hit and they're still running. But the study period ran was stopped due to due to COVID. Um So what is inspired? 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 ICU doctors, ICU nurses and physiotherapists. Um Often think of the original sort of I see or follow up clinic as a physio and a doctor and a nurse. Um But if you read the literature, actually, probably most of it was nurse lead and then with the physio input and occasionally a doctor, but we bring all of those people together, including the pharmacist because the medication problems after I see, you can be huge and then other kind of less traditional elements. So financial and welfare advice, patient's get a chance to visit the ICU. There was a psychologist, every clinic and um we kind of debrief the critical illness and alongside that patient's are brought to inspire in groups and also their caregivers, relatives are invited. We don't limit it to just one caregiver. A couple of people want to attend and that's fine. And there's a lot of down time in it which builds in a lot of peer support. And we try and set goals for people are preferably get them set their own goals and see how we go and we try and make links with the community and we try and think about that sort of returning to work or okay, occupational and vocational we have. 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 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 it could be adapted locally to be four weeks, 56 or three, whoever works. Um But basically a group of patient's and their caregivers or relatives would be invited along to the program and it might be five half days. Um So they would come, they would come together, there would be coffee, tea available a bit of down time and a chance for the patient's relatives, caregivers, family members to all interact and mingle. And 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. And, and cardiac medications are absolutely huge. The aspirin that should continue or was stopped and shouldn't have stopped. Or there's a huge amount of pharmacy stuff and, and it also feeds backwards or I see us learn from this but they also receive a 1 to 1 review by the pharmacist, physiotherapist won't necessarily be an exercise class or anything like that. 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 in referring them onto community gym or physio review or whatever. And it seems to be the main focus. It's more about chatting to the patient and kind of working out what they need and then getting them involved in community physio. And as required, the doctor, nurse will be brief of what happened. And I see a lot of patient's just, they really don't know. Um, for patient's say I have no idea had sepsis doctor or things that we thought were really obvious. And so just a debrief of what happened, which helps put a lot of things into context and for the patient will 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, but sign post um 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 with 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. But then each week we'll have a, um sort of group education sessions who might have pacing of activities which in Paisley is delivered by the physios uh chat about just building up exercise over time rather than just hammering it hard and doing nothing for a week or a month, a group psychology session. So this would ideally be delivered in two sessions, you'd separate out the patient's in the caregivers and you would get a psychology session for each one which might be involved a little presentation. And then I came a discussion. It, even if the psychologist session occurs in week four, we're into the weeds and the depths of chatting about delirium and memories and strange dreams and being on a boat and the aliens coming and, and people just, um, patient's are attending, inspire quite often, just are desperate to chat about this and work out was this normal? 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 and, and then a sleep session rich and paisleys delivered by the pharmacist. But it could have a different slant depending on local need. Um dietetics that could either be referral in or a session on that. And then occupational in vocational, we have 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 pit form or whatever or whether it's about returning to work or a change to their lifestyle and, and how that will 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. And I guess the last thing is the peer support. So that's the arrow. It just, that just keeps going weekend, week out for, for the cohorts that lasts for five weeks. Um, and hopefully the group build up a report and, and certainly it's not uncommon to have patient's exchange and four numbers of emails with each other. Most recently, we had to patient to women who had stoma is and they were in touch with each other for support with that and then volunteers. So, um, that could either just be a volunteer or it could be a previous patient who's been on a previous cohort and comes back to help us, maybe make some coffee, mingle with patient's and kind of get the chat going. So, and that, you know, just happens as the thing runs along continuously. So that's kind of rough overview. Hopefully makes sense how the program would work 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 to try and put some new medical data on this. So, um we, we didn't run a randomized clinical trial because we were trying to upscale things are funding from the Health Foundation was about feasibility and expanding the program and seeing how, how reproducible it was in other areas. And Aberdeen lead a lot in that, but we thought it'd be good to get someone year outcomes and look at actual sort of more objective measures. So, and we had to inspire groups that were running where I've already mentioned G R I Cross. How's Victoria Markham's Whishaw? 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 post ICU care and, and people's interest in it. But and we wanted as few confounder is as possible. So at that time, the QE the Rh Enver Clyde in here, Myers were accessible and we could collect data from them quite readily and they did not have um any follow up in place for the ICU patient's. They're also about 15 patient's 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 and we had a few kind of, they were, they were contemporaneous with the G R I cohorts, but they kind of were historical to the cross house Victoria Month hands with show ones. But um that all went into the mix and that was a postal survey. So certainly method a logically there's a difference in each cohort, but it was a good way to collect data and a very pragmatic way to get that information. What we measured was E Q five D. So that sort of overall health and health problems, hospital anxiety and depression scale and we measured self efficacy. So the score ranges from 10 to 40 on that. And it's about how you could um solve problems. Basically, many of the questions that 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 inspired program, was having a longer lasting effect, rather just a snapshot of right will 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, 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 I see you are well knowing, it probably was a problem and when chatting to the patient, so when inspired groups were set up, they were set up with focus groups very much directed by patient's and relatives and what they wanted and pain was a recurring theme. So we added in a brief pain inventory which is complex survey and we definitely cooked interpret, but it certainly offers a lot of insights and information. Um So obviously, uh this was a randomized control trial and the co cohorts could be prone to differences. So, um I think follow up from the intervention of Inspired, but it was pretty good. 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 seek the front, might be absolutely tiny there. But we had 5 70 going in, invited to inspire and 253. So 50% of those invited turned up to inspire and, 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 we'd like 450 odd, uh, percent surveys and we got about a quarter back which for that type of study, a postal survey isn't uncommon and we sent them reminders. We did our best to get people if we could. And if they phoned us, we would do it over the phone and things. But we didn't have in the ethics a phone call that in, for example, so it was just the postal survey. And so this would be your table one, a lot of numbers there. And I wouldn't worry too much about it. But I guess just if it was a randomized clinical trial, then p values would be against the law on 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 age, almost. We reached statistical significance. I don't think the age sort of range difference here, I don't think stands out to be absolutely huge. The lower end of 50 upper end of either side of 70 and for inter quartile ranges, um, admitting specialty was different, that was just baked in because each hospital has its own blend of medical and surgical admission. So I'm not sure we'll get away from that. And again, that's reflected in the numbers that had an operation length of stay was different. Inspire cohort at a far longer ICU and hospital length of stays. And 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. I the actual numerical values, I think just there were some outliers. So there were some patient's that came to inspire after a very long time, which I think is part of 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 rough um inclusion criteria. Anyone ventilated, anyone who was level two for a week or more was kind of a rough criteria. And, and, and we certainly stuck to that, but obviously, that's quite broad and absolute medium values though we're about 15 months follow ups completed post hospital discharge. Um So to correct for some of these confounder as we ran a regression model and included those things there. And we had the numbers to over 250 patient's so 115 and one go or 100 and 37 the other. So we could run it with, with 10, 10 areas included in our regression model. Um And, and this was our headline results. So health utility score. So that's the overall health um as determined by the E Q five D, it's a pretty strange number, but the Inspire group uh where 0.12 higher and the scale on this is 0 to 1 where zero is death and one is the best health possible. It does go negative because there are survival states that are considered worse than death and every country is a different media on that. So, um for the UK, it's about minus 0.5. And so we improve things by 0.12, which in the whole scale ends up being about seven, a half percent. It was statistically significant and perhaps most importantly, the sort of minimum clinically important difference for this survey is really well documented. It's 0.8. And I think it's fair to say we we breech that minimum threshold. So, so and I think this definitely is a signal that attendance Inspire was correlated with quite a robust in outcome of an improvement in health related quality life of, of seven, a half percent or 0.12 on that scale. And the EQ vas is much simpler to understand 0 to 100. The patient just scores. How's your health today? And there was a 12% improvement that was statistically significant and the generalized self efficacy. So that's the one I mentioned where patient's can solve problems and deal with things and it was statistically significant and, 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 and hospital anxiety and depression. So this was a logistic regression. So these are odds ratios. So, and there was a 62% reduction or lower rates of um and of depression sorry in the Inspire group. And that was statistically significant as you can see by the spleens on the right hand side and anxiety didn't achieve significance. Um So there was no big difference in anxiety, anxiety in each group. Um pain. So I mean, just ignore the thing on the right hand side. They're basically there was no strong signal of benefit for pain in the inspired group where we get a few things over the line. So things like pain interference with enjoyment life. But if I was saying that that's what inspired clinic or program achieved, then I would definitely be over selling that to you. So um the big thing of the most striking thing was almost 60% of our patient's said that they would experience pain in the last week. That's worse than everyday aches and pains or kind of normal type pain. So, and that sounds like quite a high number. And that held true in the medical group and the surgical groups, it wasn't all kind of chronic pain from wounds and, 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, the UK. 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 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 we didn't have inspired correlating with improved outcomes in terms of pain afterwards. But it's certainly something that um merits more attention in the future. Um We then went on to do some more uh stat C stuff just to see if things held true. So we basically mocked up, uh how would inspire? Look if we ran it as a randomized controlled trial and we did a propensity match score. So we'd 75 in each group and their baseline demographics all matched perfectly. And we re ran the models and we effectively got the same answer. So we had the same outcome for health utility, visual analog scale self efficacy and depression all seemed to inspire was correlated. And when we basically effectively using a propensity score matching technique, we removed the patient's that were very different in each group. And so it held up to this sort of sensitivity analysis and lastly on on the patient outcomes, uh this is just the kind of um dot Whisker plots. So the thick line is the median, looking at outcomes for the unadjusted group, which are on the left hand side before matching and then just straight up standard testing. So no regression models and no correction. So our health utility score didn't quite hold up to that sensitivity analysis. And 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 length of stay in one and a few differences in their uh medical or subject 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. 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 and jet overall health related quality of life, self efficacy and depression. And this is just to show you the outcomes. Just if you think back to the earlier slides, I showed you basically 75% of our patient's had a problem in any domain of the E Q five D. So if you could ask if you asked a group of ICU patient's, do you problems, usual activities, anxiety, depression, pain, and discomfort, mobility or self care, 75% will say they do have problems in those areas. Um This 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 patient's down this. So rather than getting rid of all their problems, it may be modifies it from moderate problems, too, too less severe problems or severe problems to just my old problems. But um there was no clear signal of one area that inspire 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. Our radar plots are all very symmetrical. So patient 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, or the in person stuff. So, to me that was quite striking that there was quite consistent problems across these five areas. Wow. And so that covers the sort of, uh, sorry, I went into the weeds of the stats there. I hope that was okay for everybody. But I think it's important for that kind of study and just a quick mention on the other aspect of things, so caregiver outcomes and basically, we looked at and the patient's could identify their primary caregiver or relative. And we did some surveys on them as well. 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 81. Um and some of the differences that you've seen in the patient paper held through them. So length of stay was slightly different. And so we, we did some regression analysis on that as well, including these variables that were important and were different. 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 care or strain and insomnia. Um So if you remember the patient outcomes inspire was correlated with a better outcome for depression. Whereas 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 you experienced by either the patient's or the caregivers. Um But that was, so you're looking at 58% reduction um in anxiety rates in an inspired group. And we also looked at insomnia and there were lower rates of insomnia and that was statistically significant on an odds ratio. So, logistic regression and carer strain again was lower correlated with lower rates and 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 method illogical and issues with this type of study, but it's probably the best we've got at this moment in time. And lastly, just to mention, it's not just the general I see you. So everything we did to this point was in a general, I see you either teaching hospital or district general, but we did look at a small group from the golden jubilee. Um So I I think my from this is cardiothoracic patient's still experience problems are similar to picks and for the rates maybe for selfcare and mobility and things might be slightly lower, but probably the rate, anxiety, depression, the same rates of pain and effect on news are all and are all pretty similar. And actually, um one year you could expect your, your ICU patient's who've gone to a specialist service. Now, you bear in mind, these weren't just the Sixers and we're making weeding tech patient's. These were, um, those that had complex length of stay. So I think they're average, they're sort of medium length of stay with six days in ICU. So these are the more complex ones. They certainly have. I consider fairly high rates of problems afterwards. And like we go into a lot more detailed, the qualitative assessment. So and certainly the anecdote and the discussion and the quality of assessment was that patient's got a lot out of it. And I did their caregivers, they still had all the same problems of delirium, muscle weakness and, and their pharmacology was certainly uh 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 all the other elements of Inspire did seem to be beneficial and numerically, the patient's seem to have similar problems to the ones that we saw. The general Inspire outcome. And this just shows the sort of anxiety and the care giver group compared to anxiety, depression in the care giver and patient groups. So they tended to start pretty high baseline and they seem to come on par with the patient's afterwards and 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 little tour of sort of cardiac stuff. It's smaller numbers, but just to show that, yeah, it doesn't matter what I see. You, you're in, I think if you start looking, start scratching the surface, you'll find your patient's have issues. Um Inspire is, is one solution. It's when way of doing things and, and certainly we've done our best to cannon 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 and then 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 patient's and caregivers afterwards. And so I think hopefully agree that picks is seems to be a problem. Uh issues with health related quality of life are comin after critical illness. And my impression is that Inspire did make a difference. I think that data supports that. And of course, in a cohort study, uh this wasn't randomized, we can only really see correlated rather than causey causation. But I think it's still fairly robust data. And yeah, it's not a randomized control 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 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 curious to know both from a data point of view but also from a personal opinion point of view, you've also got a, a well established service that had to very quickly pivot during COVID to being delivered in a virtual setup. And I know from various post intensive cares, 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 I I don't think there's a lot of data that supports one approach of the other. Um And I guess the COVID group, whatever in some ways feel like a very specific group. So and also like I stopped, like we stopped the postal survey, we would continue that a wee bit longer, but we felt if there's 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're ever likely to have that data in terms of what people do. So I guess what we've done at Paisley is we just let the patient's 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 the slightly different blend from that. Um I guess the closest thing to some data is that there are some studies out there that have looked at health technology and, and kind of looked at an app to help guide people and kind of an online psychology session, I think 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 as it wasn't as holistic or comprehensive. So I could 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 patient's 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 um, I think the peer support is difficult online. So that's the ICU steps people and other places that do stuff like that. They, a lot of try to go back to in person just because the, it happens a lot, kind of 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. It's okay. A question from Kevin Rainy here saying uh sorry, I lost that question. Have you considered a pain specialist part of the uh 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. Interesting one from Kevin. Thanks. Um my CD. Um So pain, we have an embedded pain specialist and inspire. Currently, Joe mcpeak and MD students are looking at pain specifically looking for biomarkers of pain. I think we're still early doors with that. I think the main thing is to um referral inappropriately and screen patient's and what we still do and is we do a three month follow up. So patients are seen hopefully within four months and then they will be followed up within 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 onto pain. Um And is there a return on investment for inspiring. 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 patient's too, too far down the line. 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 a hospital discharge 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 we've certainly got the patient outcomes. It helps them in terms of service improvement and that value for E Q five D that 0.8. The magic number that includes some health economic assessments. So that's actually slightly built into the tool anyway. So, and that's probably the best we've got at the moment. Um Katie Perceval is asking, hello. And you'd like to ask, did you notice a difference in socioeconomic status and your post ICU patient's who did and did not enroll and we didn't really, didn't really break down. You're kind of didn't declined invitation group. I'm wondering if the five week program of full afternoon's may have posed a barrier to some of those patients'. 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 patient's. 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 S I N D there and we had a good spread across the five socioeconomic bands and both were similar between the postal survey and the, and the end person won. 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 were more likely to get the more affluent areas, people filling it out and send 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 a decent spread across the five quintiles. Martha mcdougall is seeing a very interesting, great results. Thank you talk. 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, Ari H and I have wondered if, if she would want to be involved, but the, it wasn't part of the initial setup and it didn't appear in the focus groups for inspire. So it wasn't part of the discussion in terms of patient's. We're not asking for that and neither where caregivers, but I think inspires a flexible platform. And I would encourage anybody to look at these elements and look at what your local population needed and improve and cannot add these things on if required. And, 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? That's up to those areas. So we we the health foundation and the money for that is kind of uh that's project has ended and the areas that were taking. So we had the Victoria. So there was some representation from the East and Faith, but it's really local, 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 into some sort of health and social care partnership. 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. And uh yeah, I guess that's where the publishing the data and 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 what I'm gonna do just just now is pop a link to the feedback form for this evening into the chat. If you follow that link, you'll be able to fill in some feedback and then you will be generated your CPET certificate for attending. And we uh you'll be glad to know there's, you'll all be able to pop an hour of R C O E C P D down for this. Uh I can't see other, any other questions. So, uh thank you very much, Doctor Henderson for giving up your time to talk to. It was really nice to, I think, see a lot of multidisciplinary attendance at this, at this meeting and people who are really engaged in ICU follow up and the next uh six evening uh education update is on the 20th of April. Um and Doctor Gregory mcneal from the Royal Infirmary of Edinburgh will be talking to us about all things deteriorating. Patient. And I see you outreach, which I know is about the controversial topic in Scotland. Thank you all and hope to see you soon. Ok. Thanks for having me. Cheers all the best. Yeah.