Association of COVID-19 Acute Respiratory Distress Syndrome With Symptoms of Posttraumatic Stress Disorder in Family Members After ICU Discharge

Family centeredness of care: a cross-sectional study in intensive care units part of the European society of intensive care medicine

PURPOSE

To identify key components and variations in family-centered care practices.

METHODS

A cross-sectional study, conducted across ESICM members. Participating ICUs completed a questionnaire covering general ICU characteristics, visitation policies, team-family interactions, and end-of-life decision-making. The primary outcome, self-rated family-centeredness, was assessed using a visual analog scale. Additionally, respondents completed the Maslach Burnout Inventory and the Ethical Decision Making Climate Questionnaire to capture burnout dimensions and assess the ethical decision-making climate.

RESULTS

The response rate was 53% (respondents from 359/683 invited ICUs who actually open the email); participating healthcare professionals (HCPs) were from Europe (62%), Asia (9%), South America (6%), North America (5%), Middle East (4%), and Australia/New Zealand (4%). The importance of family-centeredness was ranked high, median 7 (IQR 6-8) of 10 on VAS. Significant differences were observed across quartiles of family centeredness, including in visitation policies availability of a waiting rooms, family rooms, family information leaflet, visiting hours, night visits, sleep in the ICU, and in team-family interactions, including daily information, routine day-3 conference, and willingness to empower nurses and relatives. Higher family centeredness correlated with family involvement in rounds, participation in patient care and end-of-life practices. Burnout symptoms (41% of respondents) were negatively associated with family-centeredness. Ethical climate and willingness to empower nurses were independent predictors of family centeredness.

CONCLUSIONS

This study emphasizes the need to prioritize healthcare providers' mental health for enhanced family-centered care. Further research is warranted to assess the impact of improving the ethical climate on family-centeredness.

Critical care beyond organ support: the importance of geriatric rehabilitation

Very old critically ill patients pose a growing challenge for intensive care. Critical illness and the burden of treatment in the intensive care unit (ICU) can lead to a long-lasting decline of functional and cognitive abilities, especially in very old patients. Multi-complexity and increased vulnerability to stress in these patients may lead to new and worsening disabilities, requiring careful assessment, prevention and rehabilitation. The potential for rehabilitation, which is crucial for optimal functional outcomes, requires a systematic, multi-disciplinary approach and careful long-term planning during and following ICU care. We describe this process and provide recommendations and checklists for comprehensive and timely assessments in the context of transitioning patients from ICU to post-ICU and acute hospital care, and review the barriers to the provision of good functional outcomes.

Impact of COVID-19 on posttraumatic stress disorder in ICU survivors: a prospective observational comparative cohort study

BACKGROUND

Posttraumatic stress disorder (PTSD) after a stay in the intensive care unit (ICU) can affect one in five ICU survivors. At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, admission to the ICU for COVID-19 was stressful due to the severity of this disease. This study assessed whether admission to the ICU for COVID-19 was associated with a higher prevalence of PTSD compared with other causes of ICU admission after adjustment for pre-ICU psychological factors.

METHODS

This prospective observational comparative cohort study included 31 ICUs. Eligible patients were adult ICU survivors hospitalized during the first wave of COVID-19 pandemic in France, regardless of the reason for admission. The prevalence of presumptive diagnosis of PTSD at 6 months was assessed using the PTSD Checklist for DSM-5 (PCL-5). Sociodemographics, clinical data, history of childhood trauma (Childhood Trauma Questionnaire [CTQ]), and exposure to potentially traumatic events (Life Events Checklist for DSM-5 [LEC-5]) were assessed.

RESULTS

Of the 778 ICU survivors included during the first wave of COVID-19 pandemic in France, 417 and 361 were assigned to the COVID-19 and non-COVID-19 cohorts, respectively. Fourteen (4.9%) and 11 (4.9%), respectively, presented with presumptive diagnosis of PTSD at 6 months (p = 0.976). After adjusting for age, sex, severity score at admission, use of invasive mechanical ventilation, ICU duration, CTQ and LEC-5, COVID-19 status was not associated with presumptive diagnosis of PTSD using the PCL-5. Only female sex was associated with presumptive diagnosis of PTSD. However, COVID-19 patients reported significantly more intrusion and avoidance symptoms than non-COVID patients (39% vs. 29%, p = 0.015 and 27% vs. 19%, p = 0.030), respectively. The median PCL-5 score was higher in the COVID-19 than non-COVID-19 cohort (9 [3, 20] vs. 4 [2, 16], p = 0.034).

CONCLUSION

Admission to the ICU for COVID-19 was not associated with a higher prevalence of PTSD compared with admission for another cause during the first wave of the COVID-19 pandemic in France. However, intrusion and avoidance symptoms were more frequent in COVID-19 patients than in non-COVID-19 patients.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT03991611, registered on June 19, 2019.

Psychological impact of medical evacuation for ICU saturation in Covid-19-related ARDS patients

PURPOSE

Psychological impact of Medical Evacuation (MEDEVAC) in Covid-19 patients is undetermined. The objectives were to evaluate: Post-traumatic Stress Disorder (PTSD) in MEDEVAC patients hospitalized in ICU for Covid-19-related acute respiratory distress syndrome (ARDS) compared to control group; anxiety, depression rates and outcomes in patients and PTSD in relatives.

MATERIAL AND METHODS

This is a retrospective multicentric 1/1 paired cohort performed in 10 ICUs in the West of France. Evaluation was performed 18 months after discharge. Patients and closest relatives performed IES-R (Impact and Event Scale-Revised) and/or HADS (Hospital Anxiety and Depression Scale) scales.

RESULTS

Twenty-six patients were included in each group. Patients were 64 ± 11 years old, with 83% male. We report 12 vs 20% of PTSD in control vs MEDEVAC groups (p = 0.7). Anxiety disorder affected 43.5 vs 28.0% (p = 0.26) and depression 12.5 vs 14.3% (p > 0.99) in control vs MEDEVAC groups. PTSD affects 33.3 vs 42.1% of closest relatives (p = 0.55). Ways of communication were adapted: video calls were more frequent in MEDEVAC patients (8.7 vs 60.9%, p < 0.01) whereas physical visits concerned more control group (45.8 vs 13.0%, p = 0.01).

CONCLUSIONS

PTSD rate were similar between groups. Adaptive ways of communication, restricted visits and global uncertainties could explain the absence of differences.

Family burden after critical illness: the forgotten caregivers

OBJECTIVE

To determine the incidence of primary caregiver burden in a cohort of family members of critically ill patients admitted to ICU and to identify risk factors related to its development in both the patient and the family member.

DESIGN

Prospective observational cohort study was conducted for 24 months.

SETTING

Hospital Universitario Clínico San Cecilio, Granada.

PATIENTS

The sample was the primary caregivers of all patients with risk factors for development of PICS (Post-Intensive Care Syndrome).

INTERVENTIONS

The follow-up protocol consisted of evaluation 3 months after discharge from the ICU in a specific consultation.

MAIN VARIABLES OF INTEREST

The scales used in patients were Barthel, SF-12, HADS, Pfeiffer, IES-6 and in relatives the Apgar and Zarit.

RESULTS

A total of 93 patients and caregivers were included in the follow-up. 15 relatives did not complete the follow-up questionnaires and were excluded from the study. The incidence of PICS-F (Family Post Intensive Care Syndrome) defined by the presence of primary caregiver burden in our cohort of patients is 34.6% (n=27), 95% CI 25.0-45.7. The risk factors for the development of caregiver burden are the presence of physical impairment, anxiety or post-traumatic stress in the patient, with no relationship found with the characteristics studied in the family member.

CONCLUSIONS

One out of 3 relatives of patients with risk factors for the development of PICS presents at 3 months caregiver burden. This is related to factors dependent on the patient's state of health.

Family members' experiences of COVID-19 visiting restrictions in the intensive care unit-A qualitative study

OBJECTIVE

To describe how family members of critically ill patients experienced the COVID-19 visiting restrictions in Sweden.

BACKGROUND

In Sweden, the response to COVID-19 was less invasive than in many other countries. However, some visiting restrictions were introduced for intensive care units, with local variations. Although there is a growing body of literature regarding healthcare professionals' and family caregivers' perspectives on visiting restriction policies, there may be inter-country differences, which remain to be elucidated.

DESIGN

This study has a qualitative descriptive design. Focus group interviews with 14 family members of patients treated for severe COVID-19 infection were conducted. The interviews took place via digital meetings during the months after the patients' hospital discharge. Qualitative content analysis was used to interpret the interview transcripts. Reporting of the study followed the COREQ checklist.

RESULTS

Two categories-dealing with uncertainty and being involved at a distance-described family members' experiences of coping with visiting restrictions during the COVID-19 pandemic. These restrictions were found to reduce family members' ability to cope with the situation. Communication via telephone or video calls to maintain contact was appreciated but could not replace the importance of personal contact.

CONCLUSIONS

Family members perceived that the visiting restriction routines in place during the COVID-19 pandemic negatively influenced their ability to cope with the situation and to achieve realistic expectations of the patients' needs when they returned home.

RELEVANCE TO CLINICAL PRACTICE

This study suggests that, during the COVID-19 pandemic, the visiting restrictions were experienced negatively by family members and specific family-centred care guidelines need to be developed for use during crises, including the possibility of regular family visits to the ICU.

PATIENT AND PUBLIC CONTRIBUTION

None in the conceptualisation or design of the study.

Prediction of post-traumatic stress disorder in family members of ICU patients: a machine learning approach

PURPOSE

Post-traumatic stress disorder (PTSD) can affect family members of patients admitted to the intensive care unit (ICU). Easily accessible patient's and relative's information may help develop accurate risk stratification tools to direct relatives at higher risk of PTSD toward appropriate management.

METHODS

PTSD was measured 90 days after ICU discharge using validated instruments (Impact of Event Scale and Impact of Event Scale-Revised) in 2374 family members. Various supervised machine learning approaches were used to predict PTSD in family members and evaluated on an independent held-out test dataset. To better understand variables' contributions to PTSD predicted probability, we used machine learning interpretability methods on the best predictive algorithm.

RESULTS

Non-linear ensemble learning tree-based methods showed better predictive performances (Random Forest-area under curve, AUC = 0.73 [0.68-0.77] and XGBoost-AUC = 0.73 [0.69-0.78]) than regularized linear models, kernel-based models, or deep learning models. In the best performing algorithm, most important features that positively contributed to PTSD's predicted probability were all non-modifiable factors, namely, lower patient's age, longer duration of ICU stay, relative's female sex, lower relative's age, relative being a spouse/child, and patient's death in ICU. A sensitivity analysis in bereaved relatives did not alter the algorithm's predictive performance.

CONCLUSION

We propose a machine learning-based approach to predict PTSD in relatives of ICU patients at an individual level. In this model, PTSD is mostly influenced by non-modifiable factors.

Impact of COVID-19 infection experience on mental health status of intensive care unit patients' family members: a real-world study

PURPOSE

Family members of patients hospitalized in intensive care unit (ICU) are susceptible to adverse psychological outcomes. However, there is a paucity of studies specifically examining the mental health symptoms in ICU patients' family members with a prior history of coronavirus disease 2019 (COVID-19) infection.

AIM

This study aimed to investigate mental health status and its influencing factors of ICU patients' family members with previous COVID-19 infection experience in China.

DESIGN

Nationwide, cross-sectional cohort of consecutive participants of family members of ICU patients from 10 provinces randomly selected in mainland China conducted between October 2022 and May 2023.

METHODS

The basic information scale, Self-rating depression scale, Self-rating Anxiety Scale, Impact of Event Scale-Revised, Pittsburgh sleep quality index, Perceived Stress Scale, Connor-Davidson resilience scale, Simplified Coping Style Questionnaire were employed to explore mental health status among participants.

RESULTS

A total of 463 participants, comprising 156 individuals in Covid-19 family member cohort (infection group) and 307 individuals in control family member cohort (control group), met inclusion criteria. The infection group exhibited significantly higher incidence of composite mental health symptoms compared to control group (P = 0.017). Multivariable logistic regression analysis revealed that being female, engaging in physical/mental labor, residing in rural areas, and having children were identified as risk factors for the development of depression, anxiety, and post-traumatic stress disorder symptoms, while medical history of surgery was protective factor. A predictive model demonstrated a favorable discriminative ability and excellent calibration.

CONCLUSION

COVID-19 infection experience regarded as new traumatic stressors worsen mental health status of ICU patients' family members.

In their absence; intensive care nurses' experiences of communicating and supporting relatives from a distance

BACKGROUND

Having a critically ill family member in the intensive care unit (ICU) is a challenging situation and ICU nurses play an important part in supporting relatives to make sense of the situation. Strict visiting policies inhibited the family's presence in ICUs during 2020-22, and the communication between nurses and families changed drastically. Information and support are at the core of the ICU nurses' profession, and the pandemic backdrop created a split between what intensive care nurses have a professional responsibility to perform and which actions were possible. To get a fuller picture, the aim of this study was: To describe intensive care nurses' experiences of communicating and supporting relatives from a distance while working during visiting restrictions.

METHOD

A qualitative descriptive design using individual and semi-structured interviews with 16 ICU nurses. The interviews were analyzed using inductive thematic analysis. This study followed the consolidated criteria for reporting qualitative research (COREQ).

RESULTS

Due to the visiting restriction during the COVID-19 pandemic, ICU nurses found themselves in a situation where proximity and time to develop an interpersonal connection with relatives disappeared overnight. The nurses' experiences of communicating with and supporting families is described in three themes: "Finding ways to create order out of chaos"; "Guiding the relatives to a fuller picture of the situation"; and "Feeling insufficient in their support".

CONCLUSION

Visiting restrictions in the ICU meant that ICU nurses missed vital information about their patients as a person, which might have had a negative effect on personalizing and centring the patient care. But using a combination of digital and audio tools helped nurses to guide the relatives to a clearer picture of the situation as a whole. The support that nurses were able to provide to relatives was often insufficient due to the visiting restriction and as a consequence, they experienced physical and psychological stress.

Anxiety and Depression in Family Members of Critically Ill Covid-19 Inpatients: Brief Psychological Interventions via Telephone, an Exploratory Study

Purpose

This study aimed to assess the level of anxiety and depression in relatives of critically ill COVID-19 patients admitted to the intensive care unit (ICU), and to perform an exploratory pilot study on the implementation of telephone psychological interventions to reduce the initial levels of anxiety and depression in this population.

Patients and Methods

Family members of COVID-19 inpatients at ICU answered GAD-7, PHQ-9 and questions on socio-demographic data. A brief psychological intervention was applied via telephone based on the needs of the participants (with adequate adaptation, with symptoms of anxiety, depression, or both). After intervention, participants completed the Patient Global Impression of Change Scale.

Results

A total of 1307 relatives were included (66.5% female), 34% and 29% had anxiety and depressive symptoms, respectively. These symptoms were associated with female gender, unemployment, and being the parent or partner of the patient. After intervention, 57.9% reported felt better, 31.3% a little better and 6.6% much better; and with emotional regulation techniques and psychoeducation, higher percentages of feeling better or much better were reported.

Conclusion

Brief interventions to reduce the psychological impact of inpatient family members could be effective but will need to be explored further in future studies.

PTSD Symptoms Among Family Members of Patients With ARDS Caused by COVID-19 After 12 Months

This study compares data on the symptoms of posttraumatic stress disorder (PTSD) among family members of patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 vs non–COVID-19 ARDS.

Anxiety and depression symptoms in relatives of moderate-to-severe traumatic brain injury survivors - A multicentre cohort

INTRODUCTION

The prevalence and risk factors of anxiety and depression symptoms in relatives of moderate to severe traumatic brain injury (TBI) survivors have not been thoroughly investigated.

METHODS

Ancillary study of a multicentric prospective randomized-controlled trial in nine university hospitals in 370 moderate-to-severe TBI patients. TBI survivor-relative dyads were included in the 6th month of follow-up. Relatives responded to the Hospital Anxiety and Depression Scale (HADS). The primary endpoints were the prevalence of severe symptoms of anxiety (HADS-Anxiety ≥ 11) and depression (HADS-Depression ≥ 11) in relatives. We explored the risk factors of severe anxiety and depression symptoms.

RESULTS

Relatives were predominantly women (80.7%), spouse-husband (47.7%), or parents (39%). Out of the 171 dyads included, 83 (50.6%) and 59 (34.9%) relatives displayed severe symptoms of anxiety and depression, respectively. Severe anxiety symptoms in relatives were independently associated with the patient's discharge at home (OR 2.57, 95%CI [1.04-6.37]) and the patient's higher SF-36 Mental Health domain scores (OR 1.03 95%CI [1.01-1.05]). Severe depression symptoms were independently associated with a lower SF-36 Mental Health domain score (OR = 0.98 95%CI [0.96-1.00]). No ICU organization characteristics were associated with psychological symptoms in relatives.

DISCUSSION

There is a high prevalence of anxiety and depression symptoms among relatives of moderate-to-severe TBI survivors at 6 months. Anxiety and depression were inversely correlated with the patient's mental health status at 6 months.

CONCLUSIONS

Long-term follow-up must provide psychological care to relatives after TBI.

Post-hospital recovery trajectories of family members of critically ill COVID-19 survivors: an international qualitative investigation

PURPOSE

The immediate impact of coronavirus disease 2019 (COVID-19) visiting restrictions for family members has been well-documented. However, the longer-term trajectory, including mechanisms for support, is less well-known. To address this knowledge gap, we aimed to explore the post-hospital recovery trajectory of family members of patients hospitalised with a critical care COVID-19 admission. We also sought to understand any differences across international contexts.

METHODS

We undertook semi-structured interviews with family members of patients who had survived a COVID-19 critical care admission. Family members were recruited from Spain and the United Kingdom (UK) and telephone interviews were undertaken. Interviews were analysed using a thematic content analysis.

RESULTS

Across the international sites, 19 family members were interviewed. Four themes were identified: changing relationships and carer burden; family health and trauma; social support and networks and differences in lived experience. We found differences in the social support and networks theme across international contexts, with Spanish participants more frequently discussing religion as a form of support.

CONCLUSIONS

This international qualitative investigation has demonstrated the challenges which family members of patients hospitalised with a critical care COVID-19 admission experience following hospital discharge. Specific support mechanisms which could include peer support networks, should be implemented for family members to ensure ongoing needs are met.

Determinants of information provided by anaesthesiologists to relatives of patients during surgical procedures

Background

Data and interventions are lacking for family-centred perioperative care in adults. Perioperative information given to relatives by nurses or surgeons is associated with improved satisfaction and fewer symptoms of anxiety for relatives and the patient themselves. However, the frequency of the provision of information by anaesthesiologists to patients' relatives during surgery has never been reported.

Methods

A cross-sectional survey was sent to French anaesthesiologists in October 2020 to inquire how often they provided information to patients' family members during surgery and what factors led to them providing information frequently (i.e. in more than half of cases).

Results

Among 607 anaesthesiologists, 53% (319/607) were male, with median age 47 (36-60) yr and nearly half (43%, 260/607) reported more than 20 years of clinical experience; most responders (96%, 580/607) mainly treated adults. Forty-nine (8%) anaesthesiologists declared that they frequently provide information to relatives during surgery. After multivariate analysis, age >50 yr, female gender, and paediatric practice were associated with providing information more frequently. Reasons for not providing information included a lack of time and dedicated space to talk to relatives. Urgent surgery or surgery lasting >2 h were identified as factors associated with provision of information to relatives.

Conclusions

Giving information to relatives during surgery is not a common practice among anaesthesiologists. It depends on individual anaesthesiologists' personal characteristics and practice. Information during surgery could be provided systematically in situations identified as being the most important by anaesthesiologists in our survey. By creating new pathways of information, we could reduce stress and anxiety of patients and relatives.

Long-term outcomes of COVID-19 intensive care unit survivors and their family members: a one year follow-up prospective study

Purpose

To describe the long-term physical, functional and mental status of COVID-19 intensive care unit (ICU) patients and their family members 1 year after ICU discharge.

Methods

We performed a prospective observational cohort study among patients admitted to the ICU for COVID-19-associated respiratory failure and their family members. Patients attended a one-year follow-up consultation with family members. Physical, functional and respiratory outcomes were collected. In addition, participants completed the Hospital Anxiety and Depression Scale and the Revised Impact of Event Scale. Qualitative components were collected during a 2-h face-to-face interview.

Results

Fifty-four patients and 42 family members were included. Thirty-four (63%) patients reported chronic fatigue and 37 (68.5%) dyspnea. Computed tomography scans were abnormal in 34 patients (72.3%). Anxiety symptoms were present in 23 (48%) patients and 26 (66%) family members, depression in 11 (23%) and 13 (33%), and post-traumatic stress disorder in 12 (25%) and 23 (55%), respectively. Visit limitation was reported as the most painful experience for family members. Numerous patients recalled nightmares that contributed to the anxiety. Long-term reconstruction was difficult for both patients and family members.

Conclusion

The vast majority of patients and their relatives reported long-term consequences on various physical and mental components, leading to a profound impact on their well-being.

Post-acute sequelae of COVID-19: understanding and addressing the burden of multisystem manifestations

Individuals with SARS-CoV-2 infection can develop symptoms that persist well beyond the acute phase of COVID-19 or emerge after the acute phase, lasting for weeks or months after the initial acute illness. The post-acute sequelae of COVID-19, which include physical, cognitive, and mental health impairments, are known collectively as long COVID or post-COVID-19 condition. The substantial burden of this multisystem condition is felt at individual, health-care system, and socioeconomic levels, on an unprecedented scale. Survivors of COVID-19-related critical illness are at risk of the well known sequelae of acute respiratory distress syndrome, sepsis, and chronic critical illness, and these multidimensional morbidities might be difficult to differentiate from the specific effects of SARS-CoV-2 and COVID-19. We provide an overview of the manifestations of post-COVID-19 condition after critical illness in adults. We explore the effects on various organ systems, describe potential pathophysiological mechanisms, and consider the challenges of providing clinical care and support for survivors of critical illness with multisystem manifestations. Research is needed to reduce the incidence of post-acute sequelae of COVID-19-related critical illness and to optimise therapeutic and rehabilitative care and support for patients.

Association between psychosocial factors and satisfaction with communication in family members of intensive care unit patients during COVID-19 pandemic: An exploratory cross-sectional study

OBJECTIVE

To investigate the relationship between satisfaction with communication and perceived stress, depressive symptoms and perceived social support among family members of critically ill.

RESEARCH METHODOLOGY/DESIGN

Exploratory, cross-sectional study was conducted.

SETTING

Private teaching hospital in Santiago, Chile.

MAIN OUTCOMES MEASURES

Family members of critically ill patients with 3-7 days of stay and respiratory support were approached. Questionnaires were used to assess satisfaction with communication (Family Satisfaction in the Intensive Care Unit-24), perceived stress (Perceived Stress Scale-10), depressive symptoms (Patient Health Questionnaire-9) and perceived social support (Medical Outcomes Study Social Support Survey). The relationship between satisfaction with communication and relevant variables was investigated using bivariate analyses and a beta regression.

RESULTS

The study included 42 family members, with 71.4% being female and 52.4% having prior critical care experience. There was a positive correlation between perceived stress and depressive symptoms (r = 0.32, p = 0.039). According to the beta regression, perceived social support (B; 95% confidence interval, 0.44 [1.05-2.29]) and the number of calls with unit staff (0.17 [1.06-1.32]) were positively associated with satisfaction with communication but negatively with college education (-1.86 [0.04-0.64]) and perceived stress (-0.07 [0.87-0.99]).

CONCLUSION

Psychosocial factors, such as higher educational level, perceived stress and perceived social support, can influence family members' evaluation of communication with staff. Current communication practices in acute care settings should be adapted to family members' psychosocial context to improve their satisfaction with the communication process.

IMPLICATIONS FOR CLINICAL PRACTICE

Critical care professionals must be aware of the influence of family member-related factors on the quality and effectiveness of the communication process. Psychosocial features of the family members are likely to impact their satisfaction with communication and should be assessed on admission and during their stay to assist clinicians to adjust and improve their communication practices.

Incidence, Risk Factors, and Consequences of Post-Traumatic Stress Disorder Symptoms in Survivors of COVID-19-Related ARDS

Purpose: To assess the prevalence of symptoms of Post-Traumatic Stress Disorder (PTSD) in survivors of COVID-19 Acute Respiratory Distress Syndrome that needed ICU care; to investigate risk factors and their impact on the Health-Related Quality of life (HR-QoL). Materials and Methods: This multicenter, prospective, observational study included all patients who were discharged from the ICU. Patients were administered the European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L) questionnaire, the Short-Form Health Survey 36Version 2 (SF-36v2), a socioeconomic question set and the Impact of Event Scale-Revised (IES-R) to assess PTSD. Results: The multivariate logistic regression model found that an International Standard Classification of Education Score (ISCED) higher than 2 (OR 3.42 (95% CI 1.28-9.85)), monthly income less than EUR 1500 (OR 0.36 (95% CI 0.13-0.97)), and more than two comorbidities (OR 4.62 (95% CI 1.33-16.88)) are risk factors for developing PTSD symptoms. Patients with PTSD symptoms are more likely to present a worsening in their quality of life as assessed by EQ-5D-5L and SF-36 scales. Conclusion: The main factors associated with the development of PTSD-related symptoms were a higher education level, a lower monthly income, and more than two comorbidities. Patients who developed symptoms of PTSD reported a significantly lower Health-Related Quality of life as compared to patients without PTSD. Future research areas should be oriented toward recognizing potential psychosocial and psychopathological variables capable of influencing the quality of life of patients discharged from the intensive care unit to better recognize the prognosis and longtime effects of diseases.

Post-traumatic stress disorder and quality of life alterations in survivors of immune-mediated thrombotic thrombocytopenic purpura and atypical hemolytic and uremic syndrome

Thrombotic thrombocytopenic purpura (iTTP) and atypical hemolytic-uremic syndrome (aHUS), once in remission, may cause long-term symptoms, among which mental-health impairments may be difficult to detect. We conducted telephone interviews 72 [48-84] months after ICU discharge to assess symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) and the 36-item Short Form questionnaire (SF-36). Of 103 included patients, 52 had iTTP and 51 aHUS; 74% were female, median age was 39 y (31-54), and 39 (38%) patients were still taking treatment. Symptoms of anxiety, PTSD and depression were present in 50%, 27% and 14% of patients, respectively, with no significant difference between the iTTP and aHUS groups. Patients with PTSD symptoms had significantly greater weight gain and significantly worse perceived physical and/or emotional wellbeing, anxiety symptoms, and depression symptoms. The SF-36 physical and mental components indicated significantly greater quality-of-life impairments in patients with vs. without PTSD symptoms and in those with aHUS and PTSD vs. iTTP with or without PTSD. In the aHUS group, quality of life was significantly better in patients with vs. without eculizumab treatment. Factors independently associated with PTSD symptoms were male sex (odds ratio [OR], 0.11; 95%CI, 0.02-0.53), platelet count ≤20 G/L at acute-episode presentation (OR, 2.68; 1.01-7.38), and current treatment (OR, 2.69; 95%CI, 1.01-7.36). Mental-health screening should be routine in patients with iTTP and aHUS to ensure appropriate care.

[Challenges of and Responses to Mental Health Problems in the Post-COVID-19 Era]

Since the first outbreak of the coronavirus disease 2019 (COVID-19), prevention and control of the pandemic remains a grim issue because of the continuous emergence of new variants of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing COVID-19, and the constant emergence of new domestic outbreaks. During the COVID-19 pandemic, mental and psychological problems have increased significantly among different populations, including patients of COVID-19 and their families, health workers, college students, adolescents, children, and even the general population. At present, the COVID-19 epidemic situation in China is rather complicated. The general population is confronted with a variety of challenges, including the threat of infection or reinfection, lower efficiency in study and work, and reduced incomes, and is hence experiencing many mental health problems related to the epidemic situation. Therefore, the relevant governmental departments and health institutions in China have attached high importance to the mental health issue in the process of implementing pandemic control measures of COVID-19. Close collaboration to implement the required epidemic prevention and control measures, improvements in the mental health services for public health emergencies in China, and commitment to the protection of the mental health and well-being of the people in the post-pandemic era have become the top priorities for now. Based on a review of the mental health problems related to COVID-19 pandemic, we suggested strategies to deal with mental health problems in the post-COVID-19 era.

One-Year Mental and Physical Health Assessment in Survivors after Extracorporeal Membrane Oxygenation for COVID-19-related Acute Respiratory Distress Syndrome

Rationale: Long-term outcomes of patients with coronavirus disease (COVID-19)-related acute respiratory distress syndrome treated with extracorporeal membrane oxygenation (ECMO) are unknown. Objectives: To assess physical examination, pulmonary function tests, anxiety, depression, post-traumatic stress disorder and quality of life at 6 and 12 months after ECMO onset. Methods: Multicenter, prospective study in patients who received ECMO for COVID-19 acute respiratory distress syndrome from March to June 2020 and survived hospital discharge. Measurements and Main Results: Of 80 eligible patients, 62 were enrolled in seven French ICUs. ECMO and invasive mechanical ventilation duration were 18 (11-25) and 36 (27-62) days, respectively. All were alive, but only 19/50 (38%) returned to work and 13/42 (31%) had recovered a normal sex drive at 1 year. Pulmonary function tests were almost normal at 6 months, except for Dl_CO, which was still impaired at 12 months. Mental health, role-emotional, and role-physical were the most impaired domain compared with patients receiving ECMO who did not have COVID-19. One year after ICU admission, 19/43 (44%) patients had significant anxiety, 18/43 (42%) had depression symptoms, and 21/50 (42%) were at risk for post-traumatic stress disorders. Conclusions: Despite the partial recovery of the lung function tests at 1 year, the physical and psychological function of this population remains impaired. Based on the comparison with long-term follow-up of patients receiving ECMO who did not have COVID-19, poor mental and physical health may be more related to COVID-19 than to ECMO in itself, although this needs confirmation.

Staff experiences, perceptions of care, and communication in the intensive care unit during the COVID-19 pandemic in Australia

BACKGROUND

In 2020, during the first wave of the COVID-19 pandemic in Australia, hospital intensive care units (ICUs) revised patient care practices, curtailed visiting, and augmented the use of personal protective equipment to protect patients, staff, and the community from viral transmission.

AIM

The aim was to explore ICU staff experiences and perceptions of care and communication with patients during the COVID-19 pandemic to understand how alternative ways of working have influenced work processes, relationships, and staff morale.

METHODS

This was a qualitative exploratory design study using audio-recorded and transcribed interviews with 20 ICU staff members. Data were analysed using thematic analysis.

FINDINGS

Four major themes were derived from the data: (i) Communication and connection, (ii) Psychological casualties, (iii) Caring for our patients, and (iv) Overcoming challenges. Patient care was affected by diminished numbers of critical care qualified staff, limited staff entry to isolation rooms, and needing to use alternative techniques for some practices. The importance of effective communication from the organisation and between clinicians, families, and staff members was emphasised. personal protective equipment hindered communication between patients and staff and inhibited nonverbal and verbal cues conveying empathy in therapeutic interactions. Communication with families by phone or videoconference was less satisfying than in-person encounters. Some staff members suffered psychological distress, especially those working with COVID-19 patients requiring extracorporeal membrane oxygenation. Moral injury occurred when staff members were required to deny family access to patients. Workload intensified with increased patient admissions, additional infection control requirements, and the need to communicate with families using alternative methods.

CONCLUSION

The results of this study reflect the difficulties in communication during the early stages of the COVID-19 pandemic. Communication between staff members and families may be improved using a more structured approach. Staff reported experiencing psychological stress when separating families and patients or working in isolation rooms for prolonged periods. A flexible, compassionate response to family presence in the ICU is essential to maintain patient- and family-centred care.

Identification of risk factors for post-intensive care syndrome in family members (PICS-F) among adult patients: a systematic review

INTRODUCTION

Relatives of critically ill patients who either die or survive the intensive care unit (ICU) may develop substantial mental health problems that are collectively defined as post-intensive care syndrome in family (PICS-F).

MATERIAL AND METHODS

By using a systematised search strategy we included studies that focused on PICS-F in relatives of adult ICU patients and reported the risk factors associated with its development. The search was conducted within PubMed, Embase, SCOPUS, clinicaltrials.gov, and Cochrane Library on the 23 August 2022. PRISMA 2020 guidelines were implemented for appropriate reporting. The objective was to document all possible risk factors associated with the development of PICS-F.

RESULTS

We included 51 papers covering 9302 relatives. The frequency of PICS-F varied between 2.5 and 69%. We identified 51 different risk factors of PICS-F, among which we distinguished patient-related ( n = 16), relative-related ( n = 27), and medical staff-related ( n = 8) risk factors. Among 21 studies of the highest quality, we identified the 33 variables associated with the development of PICS-F, of which younger age of a patient, death of a patient, depression in relatives during the ICU stay, history of mental disorders in relatives, being a female relative, being a spouse, and having low satisfaction with communication and care in the ICU were the most commonly reported risk factors.

CONCLUSIONS

PICS-F is a highly frequent phenomenon that can be exacerbated by several risk factors. Special attention should be paid to relatives of younger patients with worse prognosis and with the following relative-related risk factors: female sex, being a spouse, and history of mental health disorders. Finally, the medical staff play a role in preventing the PICS-F development, not only by maintenance of proper communication, but also by early identification of relatives prone to PICS-F.

Family caregivers' responses to a visitation restriction policy at a Korean surgical intensive care unit before and during the coronavirus disease 2019 pandemic

BACKGROUND

Since the COVID-19 pandemic, restricting family visits in the ICU has increased concerns regarding negative psychosocial consequences to patients and families.

OBJECTIVES

To compare the quality of life, depressive symptoms, and emotions in family caregivers of ICU patients before and during the COVID-19 pandemic, and to explore families' perceptions and suggestions for the visitation.

METHODS

A cross-sectional descriptive survey was conducted in 99 family caregivers of adult surgical ICU patients from an urban academic medical center in South Korea (February to July 2021). The WHO's Quality of Life-BREF, Center for Epidemiologic Studies Depression, and Visual Analogue Scale were used to assess quality of life, depressive symptoms, and emotions, respectively. The Family Perception Checklist was used to assess families' perceptions and suggestions about the visitation restriction. Results were compared with the data from our previous survey (n = 187) in 2017.

RESULTS

Family caregivers were mostly women (n = 59), adult children (n = 43) or spouse (n = 38) of patients with mean age of 47.34 years. Family caregivers surveyed during the pandemic reported worsening sadness (54.66 ± 28.93, 45.58 ± 29.44, P = 0.005) and anxiety (53.86 ± 30.07, 43.22 ± 29.02, P = 0.001) than those who were surveyed in. While majority of families were satisfied with the visitation restrictions (86.9%), only 50.5% were satisfied with the amount of information provided on the patient's condition.

CONCLUSIONS

Visitation restriction is necessary during the COVID-19 pandemic despite sadness and anxiety reported in caregivers. Hence, alternative visitation strategies are needed to mitigate psychological distress and provide sufficient information to ICU family caregivers.

Piloting Group-Based Behavioral Activation Therapy for Families of Deceased COVID-19 Patients

Surrogate decision-making is a stressful process for many family members of critically ill patients. The COVID-19 pandemic may have amplified the risk for anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms in ICU surrogates.

OBJECTIVES

This study piloted an online group-based behavioral intervention with family members of deceased COVID-19 patients. Participant engagement, perceptions, and responses related to the intervention were assessed.

DESIGN

A single-arm pilot study was conducted with bereaved families. Quantitative analysis of measures of anxiety, depression, and PTSD symptoms was conducted with mixed models. Qualitative data were analyzed to identify themes in surrogates' experiences with the intervention.

SETTING

Participants were recruited from ICUs at a tertiary academic medical center. Participants completed the intervention, measures, and interviews online.

SUBJECTS

Participants were family members of patients who died from COVID-19.

INTERVENTIONS

The intervention involved six online group-based behavioral activation sessions. Sessions covered topics pertinent to grieving and engagement in personally meaningful activities.

MEASUREMENTS AND MAIN RESULTS

Semi-structured interviews explored participants' experiences with the intervention. Surrogates also completed measures of anxiety, depression, and PTSD symptoms before and after the intervention. Nineteen of 26 participants (73.1%) completed the study. Thematic analysis suggested that surrogates found the group helpful for overcoming perceived isolation, receiving validation, and developing coping skills. Significant pre-to-post reductions were observed in symptoms of Hospital and Anxiety Disorder Scale (HADS) anxiety (pre-mean = 9.27, sd = 5.30 vs post-mean = 6.80, sd = 4.16; p = 0.0271), HADS depression (pre-mean =6 .65, sd = 4.58 vs post- mean = 4.89, sd = 3.40; p = 0.0436), and Impact of Events Scale-Revised PTSD (pre-mean = 36.86, sd = 16.97 vs post-mean = 24.14, sd = 13.49; p = 0.0008).

LIMITATIONS

This was a preliminary study based on qualitative and self-report measures. Future studies should include a control group.

CONCLUSIONS

Online group-based behavioral activation therapy appears to be a potentially useful intervention for family members of ICU patients who died from COVID-19.

Palliative care practice and moral distress during COVID-19 pandemic (PEOpLE-C19 study): a national, cross-sectional study in intensive care units in the Czech Republic

Background

Providing palliative care at the end of life (EOL) in intensive care units (ICUs) seems to be modified during the COVID-19 pandemic with potential burden of moral distress to health care providers (HCPs). We seek to assess the practice of EOL care during the COVID-19 pandemic in ICUs in the Czech Republic focusing on the level of moral distress and its possible modifiable factors.

Methods

Between 16 June 2021 and 16 September 2021, a national, cross-sectional study in intensive care units (ICUs) in Czech Republic was performed. All physicians and nurses working in ICUs during the COVID-19 pandemic were included in the study. For questionnaire development ACADEMY and CHERRIES guide and checklist were used. A multivariate logistic regression model was used to analyse possible modifiable factors of moral distress.

Results

In total, 313 HCPs (14.5% out of all HCPs who opened the questionnaire) fully completed the survey. Results showed that 51.8% (n = 162) of respondents were exposed to moral distress during the COVID-19 pandemic. 63.1% (n = 113) of nurses and 71.6% of (n = 96) physicians had experience with the perception of inappropriate care. If inappropriate care was perceived, a higher chance for the occurrence of moral distress for HCPs (OR, 1.854; CI, 1.057–3.252; p = 0.0312) was found. When patients died with dignity, the chance for moral distress was lower (OR, 0.235; CI, 0.128–0.430; p < 0.001). The three most often reported differences in palliative care practice during pandemic were health system congestion, personnel factors, and characteristics of COVID-19 infection.

Conclusions

HCPs working at ICUs experienced significant moral distress during the COVID-19 pandemic in the Czech Republic. The major sources were perceiving inappropriate care and dying of patients without dignity. Improvement of the decision-making process and communication at the end of life could lead to a better ethical and safety climate.

Trial registration: NCT04910243.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04066-1.

Systematized and efficient: organization of critical care in the future

Since the advent of critical care in the twentieth century, the core elements that are the foundation for critical care systems, namely to care for critically ill and injured patients and to save lives, have evolved enormously. The past half-century has seen dramatic advancements in diagnostic, organ support, and treatment modalities in critical care, with further improvements now needed to achieve personalized critical care of the highest quality. For critical care to be even higher quality in the future, advancements in the following areas are key: the physical ICU space; the people that care for critically ill patients; the equipment and technologies; the information systems and data; and the research systems that impact critically ill patients and families. With acutely and critically ill patients and their families as the absolute focal point, advancements across these areas will hopefully transform care and outcomes over the coming years.

Anticipating need for intensive care in the healthcare trajectory of patients with chronic disease: A qualitative study among specialists

Introduction

We investigated the reflections and perceptions of non-ICU physicians about anticipating the need for ICU admission in case of acute decompensation in patients with chronic disease.

Methods

We performed a qualitative multicentre study using semi-structured interviews among non-ICU specialist physicians. The interview guide, developed in advance, focused on 3 questions: (1) What is your perception of ICU care? (2) How do you think advance directives can be integrated into the patient’s healthcare goals? and (3) How can the possibility of a need for ICU admission be integrated into the patient’s healthcare goals? Interviews were recorded, transcribed and analysed by thematic analysis. Interviews were performed until theoretical saturation was reached.

Results

In total, 16 physicians (8 women, 8 men) were interviewed. The main themes related to intensive care being viewed as a distinct specialty, dispensing very technical care, and with major human and ethical challenges, especially regarding end-of-life issues. The participants also mentioned the difficulty in anticipating an acute decompensation, and the choices that might have to be made in such situations. The timing of discussions about potential decompensation of the patient, the medical culture and the presence of advance directives are issues that arise when attempting to anticipate the question of ICU admission in the patient’s healthcare goals or wishes.

Conclusion

This study describes the perceptions that physicians treating patients with chronic disease have of intensive care, notably that it is a distinct and technical specialty that presents challenging medical and ethical situations. Our study also opens perspectives for actions that could promote a pluridisciplinary approach to anticipating acute decompensation and ICU requirements in patients with chronic disease.

Video calls did not reduce PTSD symptoms in relatives during restricted ICU visits in the COVID-19 pandemic

To help reduce the spread of the SARS-CoV-2 virus during the COVID-19 pandemic, ICU visits were banned or restricted. Therefore, family-centered care as usually practiced was not feasible Video calls were recommended to meet relatives’ needs. The aim of this study was to investigate the effect of video calls on symptoms of post-traumatic stress disorder (PTSD) in relatives of ICU patients. This single-center study was performed during the first wave (15.03.2020‒30.04.2020; visits banned) and the second wave (01.10.20‒08.02.21: visits restricted) of the COVID-19 pandemic. The Impact of Event Scale-Revised (IES-R) was used to assess PTSD symptoms and an adapted version of the Family Satisfaction in the Intensive Care Unit 24-Item-Revised questionnaire (aFS-ICU 24R) to assess family satisfaction 3 months after ICU stay. The primary outcome was the difference in IES-R score at 3 months between the video call group (VCG) and the standard care group (SCG, no video calls). In addition, inductive content analysis of relatives’ comments regarding their satisfaction with decision-making and ICU care was performed. Fifty-two relatives (VCG: n = 26, SCG: n = 26) were included in this study. No significant difference in IES-R scores was observed between the VCG and the SCG (49.52 ± 13.41 vs. 47.46 ± 10.43, p = 0.54). During the ICU stay (mean 12 days, range 5.25‒18.75 days), the members of the VCG made a median of 3 (IQR 1‒10.75) video calls. No difference between the groups was found for conventional telephone calls during the same period (VCG: 9 calls, IQR 3.75‒18.1; SCG: 5 calls, IQR 3‒9; p = 0.12). The aFS-ICU 24R scores were high for both groups: 38 (IQR 37‒40) in the VCG and 40 (IQR 37‒40: p = 0.24) in the SCG. Video calls appeared largely ineffective in reducing PTSD symptoms or improving satisfaction among relatives affected by banning/restriction of ICU visits during the COVID-19 pandemic. Further investigations are needed to acquire more data on the factors involved in PTSD symptoms experienced by relatives of ICU patients during the COVID-19 pandemic.

Psychological distress and morbidity of family members experiencing virtual visiting in intensive care during COVID-19: an observational cohort study

Purpose

During the coronavirus disease 2019 (COVID-19) pandemic, intensive care units (ICUs) around the world introduced virtual visiting to mediate the psychological impact of in-person visiting restrictions. Our objective was to evaluate levels of distress, depression, anxiety, and stress among family members experiencing virtual visits.

Methods

Multi-centre prospective observational study recruiting adult family members of critically ill patients in the United Kingdom (UK) using a bespoke virtual visiting solution (aTouchAway). We recruited participants and administered validated questionnaires digitally via their aTouchAway account. Prior to first virtual visit, participants completed the Distress Thermometer (score range 0–10) and the Depression, Anxiety and Stress Scale (DASS)-21. Following first and subsequent virtual visits, participants repeated the Distress Thermometer and completed the Discrete Emotions Questionnaire.

Results

We recruited 2166 adult family members of ICU patients in 37 UK hospitals. Most were grown up children (33%) or spouses/partners (23%). Most (91%) were ≤ 65 years. Mean (SD) pre-virtual-visit Distress Thermometer score was 7 (2.6) with 1349/2153 (62%) reporting severe distress. Pre-visit Distress Thermometer scores were associated with relationship type (spouse/partner OR 1.65, 95% CI 1.27–2.12) but not family member age, or length of ICU stay. Mean (SD) post-visit Distress Thermometer score provided by 762 (35%) participants was 1.6 (3.2) points lower than pre-visit (P < 0.001). Of participants experiencing multiple visits, 22% continued to report severe distress. Median (IQR) pre-visit DASS-21 score was 18 (2–42) (1754 participants). Severe-to-extremely severe depression, anxiety, or stress were reported by 249 (14%), 321 (18%), and 165 (9%) participants, respectively. Participants reported a range of emotions with reassurance being the most common, anger being the least.

Conclusion

Family members exposed to COVID-19 pandemic ICU visiting restrictions experienced severe distress. One fifth of family members reported severe-to-extremely sever anxiety or depression. Distress score magnitude and prevalence of severe distress decreased after undertaking one or more virtual visits.

[Suicidology and Covid-19 Pandemic]

Seit über zwei Jahren ist die weltweite Bevölkerung der Pandemie mit dem SARS-CoV-2-Virus ausgesetzt. Die damit verbundene primäre Krankheitslast, also durch Infektionen, war und ist enorm. Sekundäre Belastungen ergaben sich durch Sorgen um die eigene und die Gesundheit enger Bezugspersonen, Trauerreaktionen im Falle des infektionsbedingten Verlustes von Angehörigen und all die gesellschaftlichen Einschränkungen im Rahmen der Pandemie-Bekämpfung. Der damit einhergehende Stress 1 resultierte – dies ist durch eine Vielzahl von Studien eindrucksvoll belegt – in einer Zunahme von psychischen Erkrankungen. So ist es zu einem deutlich verstärkten Auftreten von Depressions- und Angsterkrankungen gekommen, wobei bestimmte Bevölkerungsgruppen, wie z. B. alleinerziehende Mütter, einem besonderen Erkrankungsrisiko ausgesetzt waren (z. B. [2]). Bei Angehörigen von an Covid erkrankten Personen zeigt sich ein drastischer Anstieg von Traumafolgestörungen 3 und im Zuge der Einführung des ICD 11 mit der neuen Kategorie der prolongierten Trauerreaktion begrüßen einige Autoren diese neue diagnostische Entität gerade im Kontext der Corona-Erkrankung, weil es eben so viele Corona-Tote zu beklagen gab 4. Aber auch innerhalb der Gruppe von Personen, die an Corona erkrankten und dies einigermaßen überstanden haben, - und dies ist ja glücklicherweise die überwiegende Mehrzahl – zeigt sich noch nach einem Jahr eine deutlich erhöhte Menge von verschriebenen Psychopharmaka, im Vergleich zu einer Kontrollgruppe, als Beleg für fortbestehende psychische Symptome und eine womögliche ZNS-Beteiligung der Infektion (eine genaue Zuordnung innerhalb dieser Population zu dem als Postcovid-Syndrom bezeichneten Krankheitsbild muss noch erfolgen) 5.

Family perspectives on facilitators and barriers to the set up and conduct of virtual visiting in intensive care during the COVID-19 pandemic: a qualitative interview study

Objective

Methods

Results

Conclusion