The health and social consequences of admission to critical care: exploring behaviours in a high risk group.

Background: The critical care arena has felt the overwhelming impact of the growing problem of alcohol abuse. However, there is genuine uncertainty about current practice concerning the acute and chronic effects of alcohol dependency on outcomes in this population, despite its frequent presence in patients admitted to critical care areas. Indeed, there are more publications on alcohol as a hand washing disinfectant, than as a drug which may influence overall outcome from critical care (Gentilello 2007).

From the small body of evidence it is clear that there are a variety of detrimental effects which can occur as a consequence of alcohol dependency in critical care.  For example, alcohol dependence is independently associated with sepsis (O’Brien, Lu, Ali, Martin, Aberegg, Marsh, Lemeshow and Douglas 2007); bacterial infections such as ventilator-associated pneumonias (Gacouin, Legay, Camus, Volatron, Barbarot, Donnio, Thomas, Tulzo 2008); and a prolonged duration of mechanical ventilation (de Wit, Best, Gennings, Burnham and Moss 2007). Additionally, alcohol dependency has been associated with increased ICU and hospital mortality (O’Brien et al 2007).  It has also been identified that patients have a 50% higher risk of being readmitted to the ICU if they have chronic alcohol dependency (O’Brien et al 2007).  However, it may be prudent to recognise that none of the above evidence is British; these studies are from France and America, which may impact on the generalisability of the reported results within the British patient population.

The overall impact of alcohol dependency, including complications and detrimental effects on all disease processes in critical care, has never been extensively researched in the UK. Further, the effect of the combination of alcohol related disease and critical illness on long term outcomes has been poorly studied despite its increasing importance.  Indeed, patients with alcohol dependency have been specifically excluded from some previous studies exploring critical care experience and follow up. This dearth of research forms the main justification for this PhD.

Objectives:  Analyse the nature and complications of alcohol related admissions to critical care;

Explore the health and social consequences of alcohol related admissions to the critical care environment;

Examine the impact of critical care admission on future behaviour with regards to alcohol intake.

Study Design:  A 18 month prospective observational cohort study.

Data Collection and Measurements:  Triangulation of methodological approaches and data collection methods.

Qualitative data will be obtained via in depth semi structured interviews with patients who have previously been admitted to critical care with a background of alcohol dependency.  These interviews will focus on future decision making, behavioural changes and rehabilitation offered.

Quantitative data collection includes: reason for admission; age; sex; postcode;  Scottish Index of Multiple Deprivation; alcohol intake; APACHE II score; use of renal replacement therapy; baseline LFT’s & Gamma-GT’s; ICU & hospital length of stay and outcome; complications during the ICU stay, readmission rate  and  patient outcomes at three & six months.

Data Analysis: We will apply the findings of the semi structured interviews to an appropriate theoretical framework.  For example, Attribution Theory may be suitable for the qualitative data analysis.

Statistical analysis will be carried out to compare the characteristics of those patients who have been admitted with alcohol dependency, harmful alcohol intake and no risk/low risk individuals. The statistical analysis will include comparing proportions for categorical variables using chi squared tests and comparing means and medians for continuous variables using a Mann Whitney test, a two sample t- test, a Kruskal-Wallis test and one way ANOVA. Multivariate analysis will be utilised to adjust for confounding variables such as age, sex and APACHE II.

Potential Research Outcomes: The current (2012) daily cost of an ICU stay in the UK is approximately £2044. This combined with the socio-economic costs of excessive alcohol consumption, such as crime and disorder and loss of productivity through sickness, leads to major spending for policy makers.  This research will help to establish why patients continue to consume alcohol hazardously after intensive care and help target appropriate treatment, which could help reduce hospital length of stay and future alcohol related admissions to the acute healthcare setting.