Jack Iwashyna discusses his research into persistent critical illness in the ICU. While much of resuscitation focuses on the dramatic early minutes to hours of critical illness, many patients stay for days or weeks in the ICU. Jack wants to know, why do patients get stuck in the ICU, and what might we do better to improve their care? Jack became an ICU doctor because he loved drama. He wanted to find the golden hour. The golden hour describes the time to intervene, to make a difference, and to save people’s lives. It is an extraordinary thing to be able to do this, and it is sometimes possible. However, sometimes, it is not. Sometimes the golden hour is not there. Jack describes his experience with patients who would come into the ICU unwell. They would be treated aggressively and begin to get better. However, they would then take a turn for the worse. He describes this as a chronic critical illness. His patients were stably critically ill, and he could not work out why. This led Jack on a sabbatical year where he was afforded the opportunity to try to make sense of these people. The first question he and his team answered was, among patients who spend a long time in the ICU, how common are new, late organ failures? They discovered that in patients who are in the ICU longer than 14 days, there is an average of two new organ failures. Subsequently, Jack developed the persistent critical illness hypothesis. This states that there is a point in the ICU stay beyond which the ICU admission diagnosis and severity of illness in the first 24 hours no longer differentiates patients regarding their probability of in-hospital death. Put simply, the patient that you treat on Day 1 in ICU is different to the patient you are treating on Day 10. After Day 10 who the patient was before entering ICU matters more than what put there in the first place. Therefore, persisting critical illness defines those patients whose current reason for being in the ICU is more related to their ongoing critical illness than their original illness that took them to the ICU. Jack extrapolates his ideas surrounding persistent illness and critical care. In doing so, he raises thought provoking ideas regarding the long stay patients in the ICU. For more like this, head to our podcast page. #CodaPodcast

1. This work does not necessarily represent the views
of the U.S. Government or Department of Veterans Affairs
3 Short Stories of Persistent Critical Illness
Theodore J. Iwashyna, MD, PhD
University of Michigan
Ann Arbor VA Center for Clinical Management Research
twitter: @iwashyna
29 June 2017 – dasSMACC

2. Act 1, in which
I meet Ms. Perci Jones, and do not recognize her
Act 2, in which
Dr. Viglianti shows that Ms. Jones is not alone
Act 3, in which
Ms. Jones travels the world
Epilogue, in which
I tell you what I think I have learned so far

4. Ms. Perci Jones [pseudonym] is a 60
year old previously well-compensated
cirrhotic
Day 1: Biliary septic shock, failed ERCP,
PTC tube placed
Day 2: Kidneys fail, CRRT started
Day 3: Florid ARDS, intubated
Day 4: diarrhea, c. diff
Day 5: off pressors!
Day 6: exubated!
Day 7: IHD run, shock, back on pressors
…

5. Ms. Perci Jones [pseudonym] is a 60 year
old previously well-compensated cirrhotic
Day 1: Biliary septic shock, failed ERCP,
PTC tube placed
Day 2: Kidneys fail, CRRT started
Day 3: Florid ARDS, intubated
Day 4: diarrhea, c. diff
Day 5: off pressors!
Day 6: exubated!
Day 7: IHD run, shock, back on pressors
…
Beduneau et al (2017) Am J Resp Crit Care Med 195:772; see also the ProVENT model for prognostication, e.g. Carson et al (2012) CCM 40:1171.

6. Van den Berge (1998) Verhandelingen - Koninklijke Academie voor Geneeskunde van Belgie 60:487.
Ms. Perci Jones [pseudonym] is a 60 year
old previously well-compensated cirrhotic
Day 1: Biliary septic shock, failed ERCP,
PTC tube placed
Day 2: Kidneys fail, CRRT started
Day 3: Florid ARDS, intubated
Day 4: diarrhea, c. diff
Day 5: off pressors!
Day 6: exubated!
Day 7: IHD run, shock, back on pressors
…

7. Nelson et al (2010) Am J Resp Crit Care Med 182:464.
Ms. Perci Jones [pseudonym] is a 60 year
old previously well-compensated cirrhotic
Day 1: Biliary septic shock, failed ERCP,
PTC tube placed
Day 2: Kidneys fail, CRRT started
Day 3: Florid ARDS, intubated
Day 4: diarrhea, c. diff
Day 5: off pressors!
Day 6: exubated!
Day 7: IHD run, shock, back on pressors
…

8. Existing literature is all about
patients who were stably stuck.
Caring for Ms. Jones was all
about finding new problems.
Ms. Perci Jones [pseudonym] is a 60 year
old previously well-compensated cirrhotic
Day 1: Biliary septic shock, failed ERCP,
PTC tube placed
Day 2: Kidneys fail, CRRT started
Day 3: Florid ARDS, intubated
Day 4: diarrhea, c. diff
Day 5: off pressors!
Day 6: exubated!
Day 7: IHD run, shock, back on pressors
…
@anzic_rc @BellomoRinaldo

9. Act 1, in which
I meet Ms. Perci Jones, and do not recognize her
Act 2, in which
Dr. Viglianti shows that Ms. Jones is not alone
Act 3, in which
Ms. Jones travels the world
Epilogue, in which
I tell you what I think I have learned so far

10. Among patients who spend a long time in the ICU,
how common are new, late organ failures?
That is,
how unusual was Ms. Jones’
continuing development of
new forms of instability?
Liz Viglianti
U Michigan

11. Define a new, late organ failure
Liz Viglianti
U Michigan
Mike Sjoding
U Michigan
@msjoding
ICU LOS >14 days
(n=130)
Excluded 80 patients:
• Outside Transfers (n=39)
• Prior ICU admission (n=38)
• Other (n=3)
50 patients, with
520 patient-days

12. 0%
10%
20%
30%
0 1 2 3 4
Total Number of New Organ Failures,
ICU Day 4+
Liz Viglianti
U Michigan

13. 0%
10%
20%
30%
0 1 2 3 4
Total Number of New Organ Failures,
ICU Day 4+
Liz Viglianti
U Michigan

14. 0%
10%
20%
30%
0 1 2 3 4
Total Number of New Organ Failures,
ICU Day 4+
Liz Viglianti
U Michigan
Ms Jones!

15. Act 1, in which
I meet Ms. Perci Jones, and do not recognize her
Act 2, in which
Dr. Viglianti shows that Ms. Jones is not alone
Act 3, in which
Ms. Jones travels the world
Epilogue, in which
I tell you what I think I have learned so far

16. 0%
10%
20%
30%
0 1 2 3 4
Total Number of New Organ Failures,
ICU Day 4+
Formalizing a “persistent critical
illness” hypothesis:
there is a point in the ICU stay
beyond which
ICU-admission diagnosis and
severity of illness in the first 24 hours
no longer differentiates patients
regarding their probability of
in-hospital death.

17. Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Respiratory Medicine
Acute Characteristics
ICU Admission Diagnosis
ICU Admission Physiology
RRT in 24 hours Prior to ICU
Cardiac Arrest Prior to ICU
Time Awaiting ICU Bed
Antecedent Characteristics
Age
Demographics
Comorbidities (sparse here)
Hospital Characteristics
Time of Year

18. Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Respiratory Medicine
Hospital Outcome 10 or Fewer Days More Than 10 Days
Death 90,323 (9∙2%) 12,625 (24∙4%)
Discharge to:
Home 758,552 (77∙7%) 23,698 (49∙9%)
Rehabilitation or
Long-term Care
68,584 (7∙0%) 8,834 (17∙2%)
Other Hospital 59,627 (6∙1%) 6,082 (11∙8%)
51,509 patients who stayed 10 days or more:
5.0% of all ICU patients
32.8% of all ICU bed-days

21. Slide courtesy of Kathy Rowan, representing unpublished work by her and David Harrison. @KathyRowan101 and @DavidHarrison80

22. Act 1, in which
I meet Ms. Perci Jones, and do not recognize her
Act 2, in which
Dr. Viglianti shows that Ms. Jones is not alone
Act 3, in which
Ms. Jones travels the world
Epilogue, in which
I tell you what I think I have learned so far

23. Persistent Critical Illness
(a preliminary definition)
those patients
whose current reason for being in ICU
is now
more related to their ongoing critical illness
than their original reason for ICU
@anzic_rc

24. Fundamentally
Random
Structured
Cascades of
Failures
Unstable
Homeostasis

25. 1≠10

26. Less cross-coverage
=
More Death
(all else equal)
More cross-coverage
Sometimes a fresh look can be really good for you. See Amaral (2014) AJRCCM 189:1395.

27. Persistent Critical Illness
(a preliminary definition)
those patients whose
current reason for being in ICU
is now more related
to their ongoing critical illness
than their original reason for ICU
I would love to hear your thoughts
twitter @iwashyna or email
@anzic_rc
@msjodingLiz Viglianti
Shameless plug: interested in Implementation Science? Check out our new 3-year training program at tactical.med.umich.edu

28. It is our hypothesis that
there exists a substantial and growing group of patients
who are ICU-dependent, in the sense that they are are unable to live
for more than a few days outside of intensive-care-like services
whose current problems are driven by their ongoing cascading
critical illnesses rather than their original ICU admitting diagnosis
who account for a substantial portion of our bed-days
for whom we have little specific expertise in promoting their recovery
(as opposed to continuing their resuscitation)
but who are not immutably fated to such limbo, but rather whose
care we could improve both via improved ICU patient selection but
also by changing care & communication practices in the ICU