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To determine if the presence of in-hospital substantial acute stress symptoms, as well as substantial depressive or posttraumatic stress disorder symptoms at 3 months post-ICU, are associated with increased acute care service utilization over the course of the year following medical-surgical ICU admission.Longitudinal cohort study.Academic medical center.One hundred fifty patients who are 18 years old or older admitted to medical-surgical ICUs for over 24 hours.None.Participants were interviewed in-hospital to ascertain substantial acute stress symptoms using the Posttraumatic Stress Disorder Checklist-Civilian version. Substantial depressive and posttraumatic stress disorder symptoms were assessed using the Patient Health Questionnaire-9 and the Posttraumatic Stress Disorder Checklist-Civilian version, respectively, at 3 months post-ICU. The number of rehospitalizations and emergency department visits were ascertained at 3 and 12 months post-ICU using the Cornell Services Index. After adjusting for participant and clinical characteristics, in-hospital substantial acute stress symptoms were independently associated with greater risk of an additional hospitalization (relative risk, 3.00; 95% CI, 1.80-4.99) over the year post-ICU. Substantial posttraumatic stress disorder symptoms at 3 months post-ICU were independently associated with greater risk of an additional emergency department visit during the subsequent 9 months (relative risk, 2.29; 95% CI, 1.09-4.84) even after adjusting for both rehospitalizations and emergency department visits between the index hospitalization and 3 months post-ICU.Post-ICU psychiatric morbidity is associated with increased acute care service utilization during the year after a medical-surgical ICU admission. Early interventions for at-risk ICU survivors may improve long-term outcomes and reduce subsequent acute care utilization.

Objective The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes. Design Retrospective multicenter cohort study. Setting Five regional pediatric trauma centers affiliated with academic medical centers. Patients Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ≤ 8, International Classification of Diseases, 9th Edition, diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated Injury Severity Score ≥ 3) who received tracheal intubation for at least 48 hours in the ICU between 2007 and 2011 were examined. Interventions None. Measurements and main results Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91-0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08-0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01-0.26), and ICU PaCO2 more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06-0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98-0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58-0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63-0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53- 0.86). Conclusions Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury.