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ment (InS:PIRE) is a 5-week, post-ICU, multi-disciplinary,
peer-supported, rehabilitation programme. Patients who had
been mechanically ventilated for more than 72 h or in high-
dependency care for more than 2 weeks were invited to parti-
cipate in InS:PIRE 6–20 weeks post hospital discharge. People
who were further along the recovery trajectory, who self-referred
into InS:PIRE, were also included. Exclusion criteria for the
programme included: age less than 18 years; patients with
significant brain injuries; in-patient psychiatric patients; and
terminally ill patients. Patients were followed up at 12 months
post programme attendance. All eligible patients admitted to the
ICU were invited to join the programme. Data were collected
between September 2014 and June 2015. Complementary data
from the InS:PIRE programme has been published elsewhere
(10–12).
Setting
InS:PIRE was undertaken at Glasgow Royal Infirmary (GRI),
a large tertiary referral teaching hospital in Scotland. It has a
20-bedded general intensive care/high-dependency unit provi-
ding tertiary care for pancreatic, burn, oesophageal and plastic
surgery. The hospital serves a community of severe socio-
economic deprivation in the West of Scotland (13).
Intervention and measures
A musculoskeletal assessment was conducted by the physio
therapist (HD) during the 5-week programme (i.e. once during
the 5-week period). Patients were asked during the musculos-
keletal assessment to comment on any “new” pains since their
admission to ICU, which had been present for more than 12
weeks. In the present study this was utilized to indicate the
incidence of pain. The location of the patient’s pain was then
coded by body site.
To understand the impact of pain following discharge from
critical care, the Brief Pain Inventory (BPI) outcome measure
was used at initial assessment of patients during the InS:PIRE
programme and at a 1-year follow-up review (14). This measure
was initially developed for patients with pain related to cancer;
however, it has since been used in a wide range of patient groups
with chronic diseases and conditions, including fibromyalgia,
neuromuscular pain and post-surgical pain (15–17). The con-
sensus panel Initiative on Methods, Measurement and Pain
Assessment in Clinical Trials (IMMPACT) recommended that
the 2 domains of the BPI be used in all chronic pain clinical
trials (18). It allows patients to report their pain severity and
interference with daily life. The BPI has been found to be a
valid and reliable measure of chronic pain (19).
On the BPI, patients record the severity of their pain over
the previous 24 h, as worst, least, mean and current pain, on
a 0–10-point numerical rating scale (where 0 = no pain and
10 = worst pain imaginable). Developers of the tool recommend
that all 4 items be used in a mean score (14). The optimal cut-
off points for pain severity using the BPI are as follows: 0 = no
pain, 1–3 = mild pain, 4–6 = moderate pain, and 7–10 = severe
pain (20–21). Pain interference is measured using 7 components
to include: general activity, mood, walking ability, normal
work, relations with other people, sleep and enjoyment of life.
Interference has been recommended by the tool developers to
be scored as a mean of the 7 items (14). At 12 months all items
in this study were compared with baseline values.
Analgesics used by patients for pain prior to ICU admission
and at initial clinic attendance were recorded by the pharma-
www.medicaljournals.se/jrm
cist (PMcT) within the InS:PIRE programme. The analgesics
prescribed were then assessed according to the World Health
Organization (WHO) pain ladder, a 3-step scale used by clinici-
ans in the management of pain, which was originally developed
for cancer pain in adults (22). The WHO pain ladder outlines
the oral administration of pain-relieving drugs if pain occurs. It
consists of: step 1: non-opioids (aspirin and paracetamol); step
2: mild opioids (codeine and tramadol); step 3: strong opioids,
such as morphine. If pain occurs drugs should be prescribed
in a stepwise order until the patient is free of pain. Additional
drugs, called “adjuvants”, can also be added.
A number of patient demographics regarding the patient’s
stay in the ICU were collected from the ICU database. Also
collected was information about the patient’s socio-economic
status. The Scottish Index of Multiple Deprivation (SIMD)
is the Scottish Government’s tool for identifying socio-eco-
nomically deprived neighbourhoods (13). For the purpose of
this evaluation, the SIMD was split into quintiles; quintile 5
represents the most affluent area and quintile 1 represents the
most deprived area.
Data analysis
Patient demographics were analysed using descriptive statistics
and presented as numbers and percentages for the categorical
variables (and medians and interquartile ranges) for the conti-
nuous variables.
Inferential statistics were explored using Minitab 17.3.1 Sta-
tistical Software (2016) (23). Means, rather than medians, were
used in the analysis of the BPI pain intensity and interference
scale, as recommended by the tool developers (14). Therefore,
paired t-tests were used to compare initial and 1-year pain
intensity and interference. An unadjusted modelling strategy
utilizing binary logistic regression was undertaken to assess the
predictive capacity of a number of variables on the likelihood
that participants had “new” chronic pain after an ICU stay.
Percentages were used to represent all other results.
Ethical considerations
InS:PIRE was a service improvement project utilizing quality
improvement methodology within the ICU. Ethics approval was
sought and waived by our hospital research and development
department.
RESULTS
Patients
During this pilot study, 89 patients were invited to take
part in InS:PIRE. Of these, 49 (55%) attended, and a
final total of 47 patients received the physiotherapy
assessment. Baseline demographics for the 47 patients
are shown in Table I. The median age of participants
was 52 years (interquartile range (IQR) 43–57 years),
with a median Acute Physiologiy and Chronic Health
Evaluation (APACHE II) of 23 (IQR 18–27). The
largest group of patients came from a general medi-
cine background (40%, n = 19), while 26% (n = 12) of
patients came from general surgery and 11% (n = 5)
from gastroenterology (Table II).