11 GENERAL INTRODUCTION 1 MEASURING PREADMISSION HEALTH STATUS One of the major limitations in outcome research of ICU-survivors is the lack of baseline information regarding the patient’s health status. Due to the acute setting in the emergency ward and the ICU, obtaining a detailed picture of the premorbid status of the patients can be troublesome. Therefore, previously conducted research mainly focussed on baseline HRQoL-measures and physical functioning of elective surgical patients, although this group may be the least at risk for non-recovery.19,20 In addition, at admission a large proportion of patients is malnourished (38-78%) and physically frail (30%).21,22 In contrast to the often adopted strategy to look for single markers to predict recovery, these composite measures can provide important information on the patient’s health status at admission. The composite measure frailty has been identified as an ageing-associated reduced homeostatic reserve rendering the individual more vulnerable to adverse events.23 The frailty state is characterised by chronic undernutrition, sarcopenia, reduced energy expenditure, and a decreased metabolic rate. Several indicators -like the Clinical Frailty Scale (CFS)- can be used to assess frailty at ICU-admission.24,25 Several studies indicate patients with preadmission frailty as those that have a higher risk of hospital (risk ratio (RR), pooled: 1.71 [1.43-2.05]) and long-term mortality (RR, pooled: 1.53 [1.40-1.68]), with lower quality of life scores in the first year after ICU-admission (Figure 2).26 Due to the acute setting before and during ICU-admission, it is not always feasible to directly assess preadmission health status via the patient. Proxy measurements can be a useful tool in this instance. Retrospective assessment of health-related quality of life via proxy has been shown to be feasible and reliable in ICU-patients.28 Combining these measures with indicators of frailty and malnutrition may be a valuable tool in obtaining an integrative picture of the health status of the patient before critical illness, which can lead to improved treatment and support during and after ICU-admission. RECOVERY AFTER CRITICAL ILLNESS To improve the health status of critically ill patients, rehabilitation starts immediately after admission to the ICU-ward. Combining early mobilisation with targeted nutritional therapy has been used in an attempt to attenuate loss of muscle mass and function.29,30 However, evidence on the effectiveness of these interventions is often inconclusive due to differences in mobilisation
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