DRAFT: This module has unpublished changes.

Clinical Scenario:

            Your next patient in an acute care hospital is presenting with critical illness polyneuropathy and myopathy (CIPNM) following a four-week complicated ICU stay due to necrotizing pancreatitis.  The patient is 60 y/o, is married, and works as the manager of a bank in Washington, D.C.  He has had multiple complications during his 24 day hospital stay, including: acute respiratory distress syndrome requiring mechanical ventilation for 8 days, multiple organ failure, and sepsis.  He is finally turning a corner and PT has been ordered to initiate mobilization.  The patient and his wife both appear quite anxious regarding the “tall order” for today’s therapy session: sitting at the edge of the bed with possible transfer to a chair.  During the evaluation, they ask you the following questions:

  1. How long will it take for me to get walking again?
  2. What is the likelihood of me getting back to getting around the house/community on my own?
  3. What can I expect my quality of life to be on the road ahead? I want to be able to work, spend time with my family, and be the independent man I was before all this happened.

 

So you went to the literature to gather information about how to answer their questions!

 

Step 1: Evidence Based Review of Literature

There is limited evidence available on this topic, so you choose van der Schaaf, et al (2004)’s study looking specifically at functional outcomes in chronic illness polyneuropathy.  Durable link: http://proxygw.wrlc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=14573559&site=ehost-live

 

 

Section 1:  Is this study applicable to my clinical question?

 

  1. Is the study’s purpose applicable to my clinical question related to prognosis in CIPMN?  Why or why not?

 

Yes, this study was created with the intent to determine the probably functional outcomes of patients like this, who are coming from an acute care setting and who are dealing with CIP. This pathology is common in persons who have been in the intensive care unit, especially those who have required mechanical ventilation for over 7 days, as did this patient.

 

  1. Is the sample similar to my patient to justify that my patient would have a similar outcome?  Why or why not?

 

The sample, in general, was close but not exactly similar to this patient case. They were all men, but in average they were older, had been ventilated and in the ICU for longer, and had similar systemic inflammation. Though there is information which is noted in the case that is not included in our write-up for this patient, such as outcome measure scores at intake, I think that it is safe to say that the average patient involved in the CIP study was in a lower level of function and for a longer period of time than this patient. Therefore, I would expect him to do somewhat better than the sample patients.

 

 

 

   Section 2:  Appraisal of Outcome Measurement

 

  1. What specific outcomes were tracked over time?

 

Barthel Index, Rivermead Mobility Index, the TUG test, the SIP-68, the IPA, and the SF-36 were all tracked overtime. Some of them were assessed on intake and then again later into treatment, whereas other tests, like the SIP-68, IPA and SF-36 were initially taken at 6 and 12 months after diagnosis.

 

 

  1. The SIP-68 and the SF-36 were used to determine change in status for the subjects. Choose one of these measures (please state which one) to answer the questions below:

 

  • What does this outcome measure assess?  

 

  • Does it have established reliability and validity with this specific patient population? What is your source?

 

  • Would you use this in clinical practice in the acute care setting? Why or why not?

 

 

The SF-36 is meant to as a way of assessing general health for a wide variety of conditions in a form that would take 10 or less minutes to complete. It has been proven to be a valid measure for a variety of conditions and languages. I was not able to find any evidence that the SF-36 has been specifically validated for this condition, but there is a lot of evidence that it is highly regarded as a reliable and valid measure of general health, so I would not discount its’ ability to be valid for CIP as well.

 

For my sources, I looked up the information of the SF-36 which is available on Rehab Measures. This site states that the SF-36 is valid for several neurological pathologies (Parkinsons, SCI, and stroke) but does not specifically mention neuropathy.

 

 

 
  

 

 

   Section 3: Appraisal of Methodology

 

  1. Were all participants followed to the end of the study? ____ Yes  ____ No

Justify by answering the following:

  • What percentage of subjects have follow-up data? (Ideally this number should be > 80%)

 

  • Has the study reported the reason why some subjects do not have follow-up data?

 

No, not all of the subject who entered the study were able to be monitored until the end, for a variety of reasons. There is a high mortality rate associated with this disorder, so of the 61 subjects initially selected for the prospective study, and the 8 patients initially selected for the cross sectional study, only 2 and 3 were analyzed at a one year follow up (respectively). 19 of these patients died, 2 withdrew or were not available for the follow up, and several were lost because of a change in diagnosis or failure to obtain necessary documentation.

 
  

 

 

   Section 4:  Appraisal of Results

 

 

  1. What were the study’s results? What is your main take-away from the study?  (Do not just copy the results from the study. Please summarize in your own words the “big picture” you obtain about functional prognosis from this article.)

 

The results of this study were widely variable, despite the fact that their subject pool was small to begin with and much smaller at the final follow ups. The subjects that were able to be reassessed at one year demonstrated an overall increase in functional abilities as compared to their initial evaluation, but they did not return to their prior levels of function. Additionally, more subjects of this study died than were available for the follow up, which may be a more relevant idea to consider with respect to the patient case than the actual follow up results.

 

 

  1. What are the advantages and disadvantages of the study’s design?  List at least two of each with supporting rationale.

 

I think that it was wise of the authors to perform two studies of different designs in the same year, considering the high number of subjects who did not survive long enough to participate in the follow up. The prospective study was able to evaluate the number of people who were at risk for developing CIP and compare it to the number of people who actually were diagnosed with the disorder. This is valuable to us as clinicians because it helps to inform our perception of the likelihood of someone who has the common risk factors of CIP actually developing the disorder. The cross sectional study, on the other hand, is valuable because it demonstrates the changes in function and possible loss of life that typical patients with CIP may face.

 

I think that the major disadvantage of this study is the extremely small sample size and the even smaller number of people who were alive for the follow up. I think it would be beneficial for the authors of this article to conduct the same two studies but over the course of several years or decades in order to have a larger sample size which may better represent the population dealing with CIP.

 


Step 2:  Applying the Information to Your Patient

(We will be using these questions as a jumping off point for discussion in class)

 

  1. 1.     What thoughts do you have about sharing this information with your patient?  Any concerns?

 

I think that anytime you are disseminating information to your patient about their prognosis, it should be done cautiously and with the understanding that the patient will take your words very strongly to heart. With this particular patient, I think that the amount and type of information that you give his should be guided by the patients’ desire to understand his condition and outlook. That being said, I think there is an amount of sugar-coating that needs to come with delivering this type of information. There is a line between being cautiously optimistic and being misleading, and it is important to not cross over into the area of deceiving your patient about their likely prognosis.

 

 

  1. 2.     What strategies will you use to share this information in a way that helps the patient develop a realistic understanding of their prognosis, while also encouraging optimism?

 

In the case of this patient, there is very limited data on functional outcomes, which actually is to his benefit. I think that it would be helpful and appropriate to explain the small data pool in a way that indicates that while a low percentage of the sample returned to an improved level of function, the small sample may not be very representative of the population as a whole.

 

 

 

  1. 3.     In light of the prognosis, what other healthcare providers would be appropriate to collaborate with regarding this patient case? Provide rationale for EACH provider involved.  Include at least three health care providers who are a priority in this patient case, related to this patient’s specific questions.

 

In this case, I think that introducing social work is very important to help the patient to cope with his prognosis. The social worker may also be able to direct our patient toward support groups with similarly diagnosed patients. Additionally, I believe that the occupational therapist will be vital to help the patient get the adaptive equipment that he may need as he recovers. The OT will also help the patient to relearn how to perform their ADL’s to the best of their ability. Lastly, the physician will be the go-to clinician to help the patient get a better understanding of their current health status as well as their prognosis for the future

DRAFT: This module has unpublished changes.