Problems following discharge after intensive care

Intensive care unit follow-up clinic activities: a scoping review

The importance of ongoing post-discharge follow-up to prevent functional impairment in patients discharged from intensive care units (ICUs) is being increasingly recognized. Therefore, we conducted a scoping review, which included existing ICU follow-up clinic methodologies using the CENTRAL, MEDLINE, and CINAHL databases from their inception to December 2022. Data were examined for country or region, outpatient name, location, opening days, lead profession, eligible patients, timing of the follow-up, and assessment tools. Twelve studies were included in our review. The results obtained revealed that the methods employed by ICU follow-up clinics varied among countries and regions. The names of outpatient follow-up clinics also varied; however, all were located within the facility. These clinics were mainly physician or nurse led; however, pharmacists, physical therapists, neuropsychologists, and social workers were also involved. Some clinics were limited to critically ill patients with sepsis or those requiring ventilation. Ten studies reported the first outpatient visit 1-3 months after discharge. All studies assessed physical function, cognitive function, mental health, and the health-related quality of life. This scoping review revealed that an optimal operating format for ICU follow-up clinics needs to be established according to the categories of critically ill patients.

Patients' Dreams and Unreal Experiences During Intensive Care Unit (ICU) Hospitalization

In the intensive care unit (ICU), patients often experience fragmented memories, primarily comprising dreams and illusions. These experiences can impact psychosocial well-being, correlating with post-traumatic stress symptoms and heightened anxiety. Understanding these phenomena is crucial for holistic care. To systematically explore patients' perspectives concerning the recollection of dreams and unreal encounters during their stay in the ICU, considering pertinent clinical conditions and potential influencing factors, we conducted a comprehensive search in the PubMed/MEDLINE, Web of Science, and Scopus databases until November 20, 2023, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. From an initial pool of 288 records, a thorough screening for eligibility resulted in the inclusion of nine studies for this systematic review. These selected studies underwent evaluation using either the Critical Appraisal Skills Programme (CASP) Qualitative Checklist or the Newcastle-Ottawa Scale (NOS). All studies categorized dreams into three main types: positive, distressing (including nightmares), and neutral experiences. These were further detailed based on aspects such as time, space, senses, emotions, and distinguishing between reality and unreality. Two studies found associations between dreams and conditions like Guillain-Barré syndrome (GBS), mental abnormalities, and delirium. In one study, GBS patients had more vivid dreams, hallucinations, and delusions compared to ICU control group patients; delirious patients tend to report more frequent frightening dreams. Patients in the ICU who recalled dreams often had more severe illness, longer stays, and higher ventilation frequency. Notably, a prolonged ICU stay significantly predicted the likelihood of dream recall, as consistently observed in three other studies. This suggests that patients with prolonged ICU stays, experiencing higher dream recall, underwent extended treatments. This systematic exploration of patients' perspectives on fragmented memories underscores the connections between these experiences, clinical conditions such as GBS and delirium, and extended ICU stays. Recognizing and attending to these psychological aspects in post-ICU care is critical for alleviating the enduring emotional consequences for patients.

Prevalence and experience of fatigue in survivors of critical illness: a mixed-methods systematic review

We conducted a mixed methods systematic review to investigate the prevalence, experience and management of fatigue in survivors of critical illness. We identified 76 studies investigating fatigue or vitality in adults discharged from an intensive care unit and split the extracted data into three datasets: vitality scores from the Short Form Health Survey-36 (n = 54); other quantitative data (n = 19); and qualitative data (n = 9). We assessed methodological quality using critical appraisal skills programme tools. We adopted a segregated approach to mixed-methods synthesis. In a final step, we attributed combined results to one of four qualitative themes: prevalence and severity; contributing factors; impacts on quality of life; and assessment and management. Prevalence of fatigue ranged from 13.8 to 80.9%. Short Form Health Survey-36 vitality scores were commonly used as a marker of fatigue. Vitality scores reached a nadir approximately one month following ICU discharge (mean (SD) 56.44 (32.30); 95%CI 52.92-59.97). They improved over time but seldom reached reference population scores. Associated biological, disease-related and psychological factors included age, poor pre-morbid status, sleep and psychological disturbance. Qualitative data highlight the profound negative impact of fatigue on survivors' quality of life. Survivors seldom had any information provided on the potential impact of fatigue. No fatigue assessment tools specific to critical illness or evidence-based interventions were reported. Fatigue is highly prevalent in survivors of critical illness, and negatively impacts recovery. Further research on developing fatigue assessment tools specifically for critically ill patients and evaluating the impact of pharmacological and non-pharmacology interventions is needed.

Return to work after critical illness: a systematic review and meta-analysis

BACKGROUND

Survivors of critical illness often experience poor outcomes after hospitalisation, including delayed return to work, which carries substantial economic consequences.

OBJECTIVE

To conduct a systematic review and meta-analysis of return to work after critical illness.

METHODS

We searched PubMed, Embase, PsycINFO, CINAHL and Cochrane Library from 1970 to February 2018. Data were extracted, in duplicate, and random-effects meta-regression used to obtain pooled estimates.

RESULTS

Fifty-two studies evaluated return to work in 10 015 previously employed survivors of critical illness, over a median (IQR) follow-up of 12 (6.25-38.5) months. By 1-3, 12 and 42-60 months' follow-up, pooled return to work prevalence (95% CI) was 36% (23% to 49%), 60% (50% to 69%) and 68% (51% to 85%), respectively (τ ²=0.55, I²=87%, p=0.03). No significant difference was observed based on diagnosis (acute respiratory distress syndrome (ARDS) vs non-ARDS) or region (Europe vs North America vs Australia/New Zealand), but was observed when comparing mode of employment evaluation (in-person vs telephone vs mail). Following return to work, 20%-36% of survivors experienced job loss, 17%-66% occupation change and 5%-84% worsening employment status (eg, fewer work hours). Potential risk factors for delayed return to work include pre-existing comorbidities and post-hospital impairments (eg, mental health).

CONCLUSION

Approximately two-thirds, two-fifths and one-third of previously employed intensive care unit survivors are jobless up to 3, 12 and 60 months following hospital discharge. Survivors returning to work often experience job loss, occupation change or worse employment status. Interventions should be designed and evaluated to reduce the burden of this common and important problem for survivors of critical illness.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42018093135.

Examining the Occurrence of Adverse Events within 72 hours of Discharge from the Intensive Care Unit

Adverse events have negative consequences for patients, including increased risk of death or permanent disability. Reports describe suboptimal patient care on hospital wards and reasons for readmission to the intensive care unit (ICU) but limited data exists on the occurrence of adverse events, their characteristics and outcomes in patients recently discharged from the ICU to the ward. This prospective observational study describes the incidence and outcomes of adverse events within 72 hours of discharge from an Australian ICU over 12 weeks in 2006. Patients were excluded if they were admitted to ICU after booked surgery or uncomplicated drug overdose, were discharged from ICU to the high dependency unit or had a ‘do-not-resuscitate’ order. Clinical antecedents and preventability were determined for each event. Seventeen (10%) of the 167 discharges that met the inclusion criteria were associated with an adverse event, with nine (52%) judged as probably preventable. Seven adverse events occurred from discharges between 1700 and 0700 hours and seven were on weekends. The most common adverse events were related to fluid management (47%). Outcomes included three ICU readmissions, two high dependency unit admissions and two required one-to-one ward nursing. Two adverse events resulted in temporary disability, seven resulted in prolonged hospital stays and two were associated with death. Delay in taking action for abnormal physiological signs and infrequent charting were evident. Whilst the adverse event rate compared favourably with other reports, 64% of the events were considered preventable. A review of support systems and processes is recommended to better target transition from the ICU.

Post-intensive care outpatient clinic: is it feasible and effective? A literature review

The follow-up of patients who are discharged from intensive care units follows distinct flows in different parts of the world. Outpatient clinics or post-intensive care clinics represent one of the forms of follow-up, with more than 20 years of experience in some countries. Qualitative studies that followed up patients in these outpatient clinics suggest more encouraging results than quantitative studies, demonstrating improvements in intermediate outcomes, such as patient and family satisfaction. More important results, such as mortality and improvement in the quality of life of patients and their families, have not yet been demonstrated. In addition, which patients should be indicated for these outpatient clinics? How long should they be followed up? Can we expect an improvement of clinical outcomes in these followed-up patients? Are outpatient clinics cost-effective? These are only some of the questions that arise from this form of follow-up of the survivors of intensive care units. This article aims to review all aspects relating to the organization and performance of post-intensive care outpatient clinics and to provide an overview of studies that evaluated clinical outcomes related to this practice.

Physical Impairments Associated With Post-Intensive Care Syndrome: Systematic Review Based on the World Health Organization's International Classification of Functioning, Disability and Health Framework

BACKGROUND

Post-intensive care syndrome (PICS) is a constellation of new or worsening impairments in physical, mental, or cognitive abilities or a combination of these in individuals who have survived critical illness requiring intensive care.

PURPOSE

The 2 purposes of this systematic review were to identify the scope and magnitude of physical problems associated with PICS during the first year after critical illness and to use the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to elucidate impairments of body functions and structures, activity limitations, and participation restrictions associated with PICS.

DATA SOURCES

Ovid MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, CINAHL Plus with Full Text (EBSCO), Web of Science, and Embase were searched from inception until March 7, 2017.

STUDY SELECTION

Two reviewers screened titles, abstracts, and full text to independently determine study eligibility based on inclusion and exclusion criteria.

DATA EXTRACTION

Study methodological quality was assessed using the Newcastle-Ottawa Scale. Data describing study methods, design, and participant outcomes were extracted.

DATA SYNTHESIS

Fifteen studies were eligible for review. Within the first year following critical illness, people who had received intensive care experienced impairments in all 3 domains of the ICF (body functions and structures, activity limitations, and participation restrictions). These impairments included decreased pulmonary function, reduced strength of respiratory and limb muscles, reduced 6-minute walk test distance, reduced ability to perform activities of daily living and instrumental activities of daily living, and reduced ability to return to driving and paid employment.

LIMITATIONS

The inclusion of only 15 observational studies in this review may limit the generalizability of the findings.

CONCLUSIONS

During the first year following critical illness, individuals with PICS experienced physical impairments in all 3 domains of the ICF.

Developing and evaluating an instrument to measure Recovery After INtensive care: the RAIN instrument

Background

Measuring and evaluating patients' recovery, following intensive care, is essential for assessing their recovery process. By using a questionnaire, which includes spiritual and existential aspects, possibilities for identifying appropriate nursing care activities may be facilitated. The study describes the development and evaluation of a recovery questionnaire and its validity and reliability.

Methods

A questionnaire consisting of 30 items on a 5-point Likert scale was completed by 169 patients (103 men, 66 women), 18 years or older (m=69, SD 12.5) at 2, 6, 12 or 24 months following discharge from an ICU. An exploratory factor analysis, including a principal component analysis with orthogonal varimax rotation, was conducted. Ten initial items, with loadings below 0.40, were removed. The internal item/scale structure obtained in the principal component analysis was tested in relation to convergent and discrimination validity with a multi-trait analysis. Items consistency and reliability were assessed by Cronbach's alpha and internal item consistency. Test of scale quality, the proportion of missing values and respondents' scoring at maximum and minimum levels were also conducted.

Results

A total of 20 items in six factors - forward looking, supporting relations, existential ruminations, revaluation of life, physical and mental strength and need of social support were extracted with eigen values above one. Together, they explained 75% of the variance. The half-scale criterion showed that the proportion of incomplete scale scores ranged from 0% to 4.3%. When testing the scale's ability to differentiate between levels of the assessed concept, we found that the observed range of scale scores covered the theoretical range. Substantial proportions of respondents, who scored at the ceiling for forward looking and supporting relations and at floor for the need of social support, were found. These findings should be further investigated.

Conclusion

The factor analysis, including discriminant validity and the mean value for the item correlations, was found to be excellent. The RAIN instrument could be used to assess recovery following intensive care. It could provide post-ICU clinics and community/primary healthcare nurses with valuable information on which areas patients may need more support.

Review of Critical Illness Myopathy and Neuropathy

Critical illness myopathy (CIM) and neuropathy are underdiagnosed conditions within the intensive care setting and contribute to prolonged mechanical ventilation and ventilator wean failure and ultimately lead to significant morbidity and mortality. These conditions are often further subdivided into CIM, critical illness polyneuropathy (CIP), or the combination-critical illness polyneuromyopathy (CIPNM). In this review, we discuss the epidemiology and pathophysiology of CIM, CIP, and CIPNM, along with diagnostic considerations such as detailed clinical examination, electrophysiological studies, and histopathological review of muscle biopsy specimens. We also review current available treatments and prognosis. Increased awareness and early recognition of CIM, CIP, and CIPNM in the intensive care unit setting may lead to earlier treatments and rehabilitation, improving patient outcomes.

Sedation of Patients in Intensive Care Medicine and Nursing: ethical issues

This article focuses on the ethical aspects of medically-induced sedation and pain relief in intensive care medicine. The study results reported are part of a larger investigation of patients’ experiences of being sedated and receiving pain relief, and also families’ experiences of having a close relative under controlled sedation in an intensive care unit.

The study is based on qualitative in-depth interviews with nine nurses and six doctors working in intensive care and surgical units in a major Norwegian hospital. The textual data are interpreted according to Kvale’s method for analyzing qualitative data.

There are ethical problems regarding how to achieve an acceptable balance between a patient’s subjective well-being and the medical need for reduced sedation. The authors discuss whether some medical reasons for reduced sedation are ethically justifiable, given the actual medical knowledge available. The study also addresses the ethical consequences of reducing medically-induced sedation and the demands it puts on interdisciplinary co-operation and communication, as well as the importance of improving the quality of medical and nursing care.

Executive Dysfunction Following Critical Illness: Exploring Risk Factors and Management Options in Geriatric Populations

Cognitive impairment is a common occurrence that has been shown to occur in over 50 % of patients following critical illness. This impairment occurs across a range of domains including attention, memory, processing speed, and executive dysfunction. In this article, we will discuss the pathophysiology behind cognitive impairment including hypoxemia and cytokines. Secondly, we will describe the risk factors for cognitive impairment including age, length of stay, and delirium. Lastly, we will review emerging data related to the use of cognitive rehabilitation, formation of postintensive care clinics in qualifying patients, and potential neuropharmacologic therapy. While our chapter focuses on cognitive impairment generally, it places a particular emphasis on executive dysfunction, not because impairment occurs solely in this domain but because impairments of an executive nature may be uniquely debilitating.

Patients' and relatives' experiences of transfer from intensive care unit to wards

AIMS

This literature review looks at the evidence around transferring patients from intensive care units (ICU) to wards. The literature informs us that patients and their families experience problems when being transferred from an ICU environment and that this increases overall anxiety.

BACKGROUND

The effects of surviving critical illness often have a profound psychological impact on patients and families This study examines the experiences of adult patients, and their families, following their transfer from the ICU to the ward.

FINDINGS

Five themes emerged from this literature review: physical responses, psychological responses, information and communication, safety and security, and the needs of relatives.

CONCLUSIONS

This review reminds us that these problems can be reduced if information and communication around time of transfers were improved.

RELEVANCE TO CLINICAL PRACTICE

As critical care nurses it is essential that we prepare patients and families for transfer to wards.

Patients' transition in the intensive care units: concept analysis

BACKGROUND

Adequate preparation of critically ill patients throughout their transition experience within and following discharge from the Intensive Care Unit is an important element of the nursing care process during critical illness. However, little is known about nurses' perspectives of, and engagement in, caring for critically ill patients during their transition experiences.

AIM

This paper aims to review the literature about the concept of transition within the context of critically ill patients in the Intensive Care Unit, focusing on Intensive Care Unit nurses.

REVIEW METHOD

CINAHL, MEDLINE, OVID, Science Direct, SAGE eReference and SAGE Journal Online data bases were searched for relevant literature published since 1970.

RESULTS

The critically ill patients' transitions in Intensive Care Units are generally described as a period of transfer or change of situation, or the experience of inner change or role during and after the illness. The critically ill patients' transition experience per se is not directly described, nor is nurses' understanding of it.

CONCLUSION

Nurses' understanding of critically ill patients' transition may significantly impact the patients' care in the Intensive Care Unit. Thus, research is needed that focuses more on evaluating nurses' understanding of patients' transition and its consequences.

Challenges and possible solutions for long-term follow-up of patients surviving critical illness

INTRODUCTION

Surviving critical illness can be life-changing and present new healthcare challenges for patients after discharge from hospital. Optimisation of recovery, rather than mere survival, is an important goal of intensive care. Observational studies have identified decreased quality of life and increased healthcare needs for survivors but loss to follow-up can be high with possible selection bias. Patients in need of support may therefore not be included in study results or allocated appropriate follow up support.

AIM

To examine the frequency and reasons patients admitted to general ICUs who survive critical illness are excluded from study participation or lost to follow-up and consider the possible implications and solutions.

METHOD

The literature review included searches of the MEDLINE, EMBASE, and CINAHL databases. Studies (2006-2010) were included if they described follow-up of survivors from general ICUs.

RESULTS

Ten studies were reviewed. Of the 3269 eligible patients, 14% died after hospital discharge, 27% declined, and 22% were lost to follow-up. Reasons for loss to follow-up included no response, inability to contact the patient, too ill or admitted to another facility.

CONCLUSION

The most appropriate method of care follow-up has yet to be established but is likely to involve an eclectic model that tailors service provision to support individual patient needs. Identifying methods to minimise loss to follow-up may enhance interpretation of patients' recovery, lead to improvements in clinical practice and inform healthcare service decisions and policy.

The effect of nurse-facilitated family participation in the psychological care of the critically ill patient

AIM

This paper is a report of a Neuman systems model-guided study of the effects of nurse-facilitated family participation in psychological care on the extent of patient delirium and psychological recovery following critical illness.

BACKGROUND

Psychological disturbances resulting from critical illness have been well documented in international literature. Few studies have tested interventions designed to alleviate such disturbances.

METHODS

A comparative time series design was used. A total of 170 critically ill patients and families participated in the study - 83 in the control group and 87 in the intervention group. Data were collected during critical illness and subsequent recovery using the Therapeutic Intervention Scoring System-28, Intensive Care Delirium Screening Checklist and the Sickness Impact Profile. The study was carried out in Northern Ireland, data collection taking place from January 2004 to December 2005.

RESULTS/FINDINGS

Nurse-facilitated family participation in psychological care did not significantly reduce the incidence of delirium among patients in critical care, but patients receiving intervention demonstrated better psychological recovery and wellbeing than the control group at 4, 8 and 12 weeks after admission to critical care.

CONCLUSION

Nurse-facilitated family participation in the psychological care may strengthen the lines of defence and resistance against the stressors experienced by the patient during critical illness and improve psychological recovery.

Critical care nurses' experiences of follow-up visits to an ICU

AIM

The aim of this study was to describe critical care nurses' experiences of follow-up visits for formerly critically ill people discharged from an intensive care unit and their close relatives.

BACKGROUND

The critical illness experience affects the ill person and their close relatives not only during the stay in an intensive care unit, but also for a long time afterwards. Follow-up visits were introduced to offer people the opportunity to talk about their experiences. This activity has not been studied earlier from the perspective of critical care nurses.

DESIGN

The design of this study was qualitative.

METHOD

Eight critical care nurses narrated their experiences of follow-up visits by formerly critically ill people and their close relatives to an intensive care unit. Data were collected during 2007-2008. Qualitative thematic content analysis was applied to the interview texts.

RESULTS

The findings show that to feel they were doing a good job it was vital for the critical care nurses to be well prepared for the follow-up visits. It was difficult, in a positive way, to recognise formerly critically ill people when they returned looking healthy. The critical care nurses were disappointed that their former patients remembered so few real events. The follow-up visits gave the critical care nurses a new picture of how the critically illness experience influenced the former patient's everyday life during and after their stay in the intensive care unit and how it affected the lives of their close relatives.

CONCLUSIONS

Through sharing the experiences of formerly critically ill peoples' and their close relatives' critical care nurses receive valuable feedback about their work.

RELEVANCE TO CLINICAL PRACTICE

Receiving feedback about one's work from follow-up visits gives critical care nurses the possibility for to evaluate given care. Follow-up visits to intensive care units can provide them with valuable knowledge that might lead to improved nursing care.

Patients' recovery after critical illness at early follow-up

AIM

To determine the quality of life, particularly physical function, of intensive care survivors during the early recovery process.

BACKGROUND

Survivors of critical illness face ongoing challenges after discharge from the intensive care unit and on returning home. Knowledge about health issues during early phases of recovery after hospital discharge is emerging, yet still limited.

DESIGN

Descriptive study where the former critically ill patients completed instruments on general health and quality of life (SF-36) in the first six months of recovery.

METHODS

Participants responded to the SF-36 questionnaire and questions about problems, one to six months after intensive care, either face-to-face or by telephone.

RESULTS

Thirty-nine participants had a mean age of 60 years; of them, 59% were men and had been in intensive care for 1-69 days (median = 5). Most participants (69%) rated their health as good or fair, but 54% rated general health as worse than a year ago. Mean quality of life scores for all scales ranged from 25-65.5%, with particularly low scores for Role-Physical (25) and Pain (45.1). Half the participants reported difficulty with mobility, sleep and concentration, and 72% that their responsibilities at home had changed. No relationships were found between SF-36 scores and admission diagnosis, gender, age or length of intensive care stay.

CONCLUSIONS

These survivors of critical illness and hospitalisation in an intensive care unit perceive their general health to be good despite experiencing significant physical limitations and disturbed sleep during recovery.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of issues in these early phases of recovery and discussion and resolution of patient problems could normalise the experience for the patient and help to facilitate better quality of life.

Healthcare Utilisation among Patients Discharged from Hospital after Intensive Care

Surviving critical illness can be life-changing and presents new healthcare challenges for patients after hospital discharge. This feasibility study aimed to examine healthcare service utilisation for patients discharged from hospital after intensive care unit stay. Following Ethics Committee approval, patients aged 18 years and older were recruited over three months. Those admitted after cardiac surgery, discharged to another facility or against medical advice were excluded. Patients were informed of the study by post and followed-up by telephone at two and six months after discharge. General practitioners were also contacted (44% responded). Among 187 patients discharged from hospital, 11 died, 25 declined to participate and 39 could not be contacted. For 112 patients (60%) who completed a survey, the majority (82%) went home from hospital and were cared for by their partner (53%). More than half of the patients (58%) reported taking the same number of medications after intensive care unit stay but 30% took more (P=0.023). While there was no change in the number of visits to the general practitioner for 64% of patients, 29% reported an increase after intensive care unit stay. At six months, 40% of responders who were not retired were unemployed. Discharge summary surveys revealed 39 general practitioners (71%) were satisfied with details of ongoing healthcare needs. Twenty-one general practitioners wrote comments: 10 reported insufficient information about ongoing needs/rehabilitation and two reported no mention of intensive care unit stay. Survivors of critical illness had increased healthcare needs and despite most returning home, had a low workforce participation rate. This requires further investigation to maximise the benefits of survival from critical illness.

Long-term effect of the ICU-diary concept on quality of life after critical illness

BACKGROUND

Critically ill patients often spend time in the intensive care unit (ICU) either unconscious or sedated. On recovery, they are often in a state of confusion with memory loss that may be associated with a longstanding reduction in health-related quality of life (QoL). We hypothesised that the ICU-diary concept could improve their QoL by filling in their memory gaps.

METHODS

A non-randomised, prospective study in a non-academic eight-bedded general ICU. A group of patients (n=38) were selected to receive the ICU-diary concept (keeping a diary with photos while on the ICU plus a follow-up meeting) when a long and complicated course was expected. Health-related QoL at 6, 12, 24 and 36 months was compared with a group that did not receive the ICU-diary (n=224). The Medical Outcomes Study 36-Item Short-Form (SF-36) was used to measure health-related QoL. Multiple regression models adjusted for age, sex, illness severity, pre-existing disease and diagnostic category was used to analyse the effects of the ICU-diary concept at 6 months, and changes over time were analysed using repeated measures MANOVA.

RESULTS

Crude and adjusted scores for two dimensions of SF-36 (general health and vitality) and the physical component summary score were significantly higher at 6 months in the ICU-diary group (P<0.05) and some of the effects remained during the 3-year follow-up period (P<0.05).

CONCLUSION

The ICU-diary concept was associated with improved health-related QoL during the 3-year follow-up period after a critical illness. The effect of this intervention needs to be confirmed in a larger randomised study.

Effect of an episode of critical illness on subsequent hospitalisation: a linked data study

Healthcare utilisation can affect quality of life and is important in assessing the cost-effectiveness of medical interventions. A clinical database was linked to two Australian state administrative databases to assess the difference in incidence of healthcare utilisation of 19,921 patients who survived their first episode of critical illness. The number of hospital admissions and days of hospitalisation per patient-year was respectively 150% and 220% greater after than before an episode of critical illness (assessed over the same time period). This was the case regardless of age or type of surgery (i.e. cardiac vs non-cardiac). After adjusting for the ageing effect of the cohort as a whole, there was still an unexplained two to four-fold increase in hospital admissions per patient-year after an episode of critical illness. We conclude that an episode of critical illness is a robust predictor of subsequent healthcare utilisation.

What patients think about ICU follow-up services: a qualitative study

Introduction

UK policy recommendations advocate the use of intensive care unit (ICU) follow-up services to help detect and treat patients' physical and emotional problems after hospital discharge and as a means of service evaluation. This study explores patients' perceptions and experiences of these services.

Methods

Thirty-four former ICU patients were recruited throughout the UK, using maximum variation sampling to achieve as broad a range of experiences of the ICU as possible. Participants were interviewed at home by a qualitative researcher unconnected to their hospital care. Interviews were recorded and transcribed for analysis. We report a qualitative thematic analysis of patients' experiences of ICU follow up.

Results

Former patients said they valued ICU follow-up services, which had made an important contribution to their physical, emotional and psychological recovery in terms of continuity of care, receiving information, gaining expert reassurance and giving feedback to ICU staff. Continuity of care included having tests and being monitored, referrals to other specialists and ICU follow-up appointments soon after hospital discharge. Information about physical, emotional and psychological recovery was particularly important to patients, as was information that helped them make sense of their ICU experience. Those without access to ICU follow-up care often felt abandoned or disappointed because they had no opportunity to be monitored, referred or get more information.

Conclusions

Former patients value having ICU follow-up services but many found that their healthcare needs were unmet because hospitals were unable to provide the aftercare they required. Most participants were aware of the financial constraints on the health system. Although they valued ICU follow-up care, they did not want it to continue indefinitely, with many of them declining appointment invitations when they themselves felt they no longer needed them.

Transfer out of intensive care: a qualitative exploration of patient and family perceptions

OBJECTIVE

To examine perceptions of ICU transfer held by patients and their family members, focusing specifically on those aspects of transfer perceived as difficult and those perceived as helpful.

DESIGN

Descriptive qualitative case study design.

SETTING

General ICU of a large regional Australian teaching hospital.

PATIENTS

A total of 7 patients and 6 family members were purposefully recruited at one-month post-discharge from hospital. Participants were selected for their ability to recall ICU transfer, the involvement of family members and their ability to articulate their experiences.

MAIN OUTCOME MEASURES

Two focus groups (one for patients and one for families) were conducted in the hospital setting, aimed at capturing the individual and collective perceptions of transfer out of intensive care.

RESULTS

Four themes emerged from the data that reflected the complex and emotional nature of transfer out of intensive care. These themes included (1) a sense of sudden abandonment (2) pervasive feelings of vulnerability and helplessness, (3) a loss of importance and (4) ambivalence about the experience.

CONCLUSIONS

The need for ICU nurses, ward nurses and affiliated healthcare professionals to provide emotional support throughout ICU transfer is the most significant implication of the study. Strategies to provide this support must be developed, implemented and evaluated.

A qualitative study exploring patients perceived quality of life following an emergency liver transplant for acute liver failure

Liver transplantation is now an accepted and successful therapy for both acute and chronic liver diseases. Whilst the study of health related quality of life (HRQoL) post-transplantation for chronic liver disease (CLD) has been well documented, there is little data measuring HRQoL following liver transplantation for acute liver failure (ALF), despite super urgent transplantation constituting 16.6% of all United Kingdom liver transplantation. Therefore, the aim of the present study was to document the HRQoL in patients who have received an emergency liver transplant for ALF. Data collection employed between method triangulation, using the Short Form 36 quality of life health questionnaire for both ALF (n=47) and CLD (n=49), and six semi-structured interviews. Only the qualitative element of the study is reported here. Phenomenological analysis of the semi-structured interviews identified four themes relating to the physical changes encountered (inactivity), physical recovery (health transition); changes made to the transplant recipients life styles (modification); and outlook. The majority of transplanted ALF transplant recipients' stated that they have a good quality of life, which was often comparable to their pretransplantation lifestyle. However, the initial recovery process was often difficult and was related to the physical changes instigated from their multi-organ failure and intensive care stay, which can present numerous physical and emotional challenges.

Factual memories of ICU: recall at two years post-discharge and comparison with delirium status during ICU admission - a multicentre cohort study

AIMS AND OBJECTIVE

To examine the relationship between observed delirium in ICU and patients' recall of factual events up to two years after discharge.

BACKGROUND

People, the environment, and procedures are frequently cited memories of actual events encountered in ICU. These are often perceived as stressors to the patients and the presence of several such stressors has been associated with the development of reduced health-related quality of life or post-traumatic stress syndrome.

DESIGN

Prospective cohort study using interview technique.

METHOD

The cohort was assembled from 152 patients who participated in a previously conducted multi-centre study of delirium incidence in Australian ICUs. The interviews involved a mixture of closed- and open-ended questions. Qualitative responses regarding factual memories were analysed using thematic analysis. A five-point Likert scale with answers from 'always' to 'never' was used to ask about current experiences of dream, anxiety, sleep problems, fears, irritability and/or mood swings. Scoring ranged from 6 to 30 with a mid-point value of 18 indicating a threshold value for the diagnosis of post-traumatic stress syndrome. A P-value of <0.05 was considered significant for all analyses.

RESULTS

Forty-one (40%) out of 103 potential participants consented to take part in the follow-up interview; 18 patients (44%) had been delirious and 23 patients (56%) non-delirious during the ICU admission. The non-participants (n = 62) formed a control group to ensure a representative sample; 83% (n = 34) reported factual memories either with or without recall of dreaming. Factual memories were significantly less common (66% cf. 96%) in delirious patients (OR 0.09, 95%CI 0.01-0.85, p = 0.035). Five topics emerged from the thematic analysis: 'procedures', 'staff', 'comfort', 'visitors', and 'events'. Based on the current experiences, five patients (12%, four non-delirious and one delirious) scored > or =18 indicative of symptoms of post-traumatic stress syndrome; this did not reach statistical significance. Memory of transfer out of ICU was less frequent among the delirious patients (56%, n = 10) than among the non-delirious patients (87%, n = 20) (p = 0.036).

CONCLUSION

Most patients have factual memories of their ICU stay. However, delirious patients had significantly less factual recall than non-delirious patients. Adverse psychological sequelae expressed as post-traumatic stress syndrome was uncommon in our study. Every attempt must be made to ensure that the ICU environment is as hospitable as possible to decrease the stress of critical illness. Post-ICU follow-up should include filling in the 'missing gaps', particularly for delirious patients. Ongoing explanations and a caring environment may assist the patient in making a complete recovery both physically and mentally.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the need for continued patient information, re-assurance and optimized comfort. While health care professionals cannot remove the stressors of the ICU treatments, we must minimize the impact of the stay. It must be remembered that most patients are aware of their surroundings while they are in the ICU and it should, therefore, be part of ICU education to include issues regarding all aspects of patient care in this particularly vulnerable subset of patients to optimize their feelings of security, comfort and self-respect.

Cognitive sequelae in acute respiratory distress syndrome patients with and without recall of the intensive care unit

Some critically ill patients have dramatic recollections of the intensive care unit (ICU), whereas 23-50% have little or no recollection of their ICU stay. In addition, cognitive impairments are common following critical illness and ICU treatment. Little is known regarding the relationship between cognitive sequelae and ICU recall. We assessed recall of the ICU and its relationship to cognitive functioning at hospital discharge and 1 and 2 years after discharge in 70 consecutive acute respiratory distress syndrome (ARDS) patients. Seventeen patients (24%) had no recall of the ICU. Patients without ICU recall had increased rates of cognitive sequelae at hospital discharge and 1-year follow-up compared with the ICU recall group. Patients without ICU recall had a greater magnitude of cognitive impairments at hospital discharge, but not at 1- or 2-year follow-up. Profile analysis showed significant group differences in general intellectual functioning, executive function, processing speed, and spatial skills at hospital discharge, but not at 1- or 2-year follow-up. Estimated premorbid intelligence scores were inversely related to the magnitude of cognitive sequelae, suggesting greater "cognitive reserve" in patients with fewer cognitive decrements.

Co-ordination of the discharge planning process in critical care

AIM AND OBJECTIVES

This article reports on the current discharge planning beliefs in relation to the co-ordination of the discharge planning process in the critical care environment in the health care system in the state of Victoria, Australia. As there is a paucity of previous studies examining discharge planning in critical care nursing knowledge about the phenomena is consequently limited.

BACKGROUND

The study reported here is part of a larger study exploring critical care nurses' perceptions and understanding of the discharge planning process in the health care system in the state of Victoria, Australia. While a number of different discharge planning models are reported in the literature there is no agreement on the most effective or the most efficient model.

DESIGN

An exploratory descriptive research design was used for this study.

METHODS

A total of 502 Victorian critical care nurses were approached to take part in the study. A total of 218 participants completed the survey, which represented a nett response rate of 43.4%. The data from the questionnaire were entered into the Statistical Package for Social Sciences (SPSS) Base 10.0. This allowed calculation of descriptive statistics and statistical analysis using chi-square test for goodness-of-fit.

RESULTS

While just over half the participants reported that the discharge planning process in their unit was co-ordinated by a combination of personnel that included a nurse, just under half the participants believed that this was an appropriate model. Another key finding was of those participants who worked in critical care units using primary nursing, just over half responded that the bedside nurse/primary nurse co-ordinated the discharge planning process while just under half responded that a combination of health care team members, including a nurse, co-ordinated the process. Overall there was little support for the designated discharge planning nurse to co-ordinate the process.

CONCLUSIONS

The findings presented here suggest critical care nurses need to examine who has the ultimate responsibility of co-ordinating the critical care patient's discharge plan irrespective of the nursing model employed within the critical care ward. There is the need to ensure that when discharge planning becomes everybody's responsibility it ultimately does not become no-one's responsibility.

RELEVANCE TO CLINICAL PRACTICE

If discharge planning practices are to be changed with the introduction of new discharge planning models in the critical care environment then it is important not only to know current practice but also the perceptions of critical care nurses in terms of who they believe should co-ordinate the discharge planning process.

A transition from nurse to touch therapist--a study of preparation before giving tactile touch in an intensive care unit

Tactile touch is a complementary therapy that is rarely undertaken in intensive care units (ICUs) in Sweden. This study was a part of a larger project that examines whether tactile touch can relieve the suffering of patients in the ICU. The aim of this study was to describe nurses' lived experience of preparation before giving tactile touch in an ICU. Four assistant nurses and one registered nurse, each with diplomas in tactile touch working at three different ICUs in Sweden, participated in the study. A phenomenological approach was chosen to achieve experience-based and person-centred descriptions. Data were collected through interviews and analysed following Giorgi's method. The main finding was that before providing tactile touch, the nurses needed to add the new role as touch therapists, to their professional one. The essential aspect being the transition from nurse to touch therapist. Findings included a general structure, with four constituents; a sense of inner balance, an unconditional respect for the patients' integrity, a relationship with the patient characterised by reciprocal trust, and a supportive environment. Furthermore, the study underlines the difficulties to integrate a complementary caring act, such as tactile touch, in a highly technological environment.

Factors that enhance or impede critical care nurses' discharge planning practices

INTRODUCTION

Any illness that is serious enough to require admission to the critical care unit will intensify the physical and psychological effects that the patient and their significant others experience. Hence, the discharge needs of patients admitted to critical care are unquestionably complex, diverse and dynamic.

METHODS

Utilising an exploratory descriptive approach 502 critical care nurses, identified from the Australian College of Critical Care Nursing (ACCCN) (Victoria) database were invited to participate in this study. A 31-item questionnaire was developed and distributed. A total of 218 eligible participants completed the survey. One-to-one semi-structured interviews with 13 Victorian critical care nurses were also conducted.

RESULTS

Participants reported that a lack of time was a barrier to discharge planning. Communication however, could enhance or impede the discharge planning process in critical care. Participants considered that the critical pathway, used in the care of cardiothoracic patients, did assist with communication of discharge planning processes, hence enhancing the process.

CONCLUSIONS

While these findings provide some understanding of the factors that enhanced or impeded critical care nurses' discharge planning practices further research is indicated. The findings reported here may, however, provide a starting point for improving the discharge planning process in critical care.

Does intermediate care minimize relocation stress for patients leaving the ICU?

Relocation stress is a phenomenon in which physical and psychological disturbances are experienced following transfer from one environment to another [Carpenito LJ. (2000). Nursing Diagnosis. Application to Clinical Practice, 8th edn]. The purpose of this review was to identify whether a period of intermediate care minimizes the problems associated with relocation stress after discharge from the intensive care unit (ICU) and before transfer to the ward. Methods of retrieving the literature involved identifying key terms, utilizing a range of databases and applying specific criteria in order to delineate the boundaries of the search. Using electronic and manual search methods, 11 studies were selected, both primary and secondary research. Following tabulation and critiquing of the studies, the findings of the review suggest that the factors which contribute towards relocation stress are the loss of one-to-one nursing, a reduction of visible monitoring equipment, lack of continuity of care and inadequate preparation of the patient for the transfer. The evidence also indicates that in order to minimize these factors, early planning and preparation of the patient for transfer are required, incorporating strategies of gradual reduction in nursing attention and monitoring equipment and the provision of information. Although the benefits of intermediate care are established as being advanced monitoring, appropriate nurse-to-patient ratio, heightened demonstration of expert knowledge and skill, there is no sufficient evidence to indicate a period of intermediate care that can ease the transition from the ICU to the ward.

A qualitative study of the experiences of patients following transfer from intensive care

In nursing literature much attention has been paid to patients' experiences while in intensive care. Extensive literature exists examining the longer-term effects of critical care [Jones C, Humphris GM, Griffiths RD. Psychological morbidity following critical illness - the rationale for care after intensive care. Clinical Intensive Care 1998;9:199-205; Griffiths RD, Jones C. ABC of intensive care. Recovery from intensive care. Br Med J 1999;319:417-429]. There is an apparent scarcity of data examining patients' experiences immediately following discharge to wards. A Husserlian phenomenological approach was utilised to gain some understanding of the experience of patients following transfer from intensive care. Ten patients selected purposively comprised the sample. Interviews were performed on the wards 3-5 days following transfer from intensive care. Data was analysed utilising () [Colaizzi PF. Psychological Research as the phenomenologist views it. In: Valle R, King M, editors. Alternatives for psychology. New York: Oxford University Press; 1978. p. 48-71] procedural approach to phenomenological interpretation and analysis. Three major themes emerged: physical response, psychological response and provision of care. These provide a possible framework for patient assessment. Implications for future practice and study are discussed.

How do critical care nurses define the discharge planning process?

BACKGROUND

Professional, political and organisational factors have focused attention on the discharge planning process in the Victorian health care sector. Discharge planning for patients, as part of continuity of care, is seen as a key concept in the delivery of nursing care. However, there is no question that discharge planning has emerged as a complex area of practice, and is, perhaps, most complex in the critical care area.

AIM

The study reported here is part of a larger thesis exploring critical care nurses' perceptions and understanding of the discharge planning process in the health care system in the state of Victoria, Australia. As part of the survey participants were asked to define discharge planning as it related to the critical care environment in which they worked.

METHODS

Utilising an exploratory descriptive approach, 502 Victorian critical care nurses were approached to take part in the study. The resultant net total of 218 participants completed the survey, which represented a net response rate of 43.4%. The data were analysed using quantitative and qualitative methodologies.

FINDINGS

Three common themes emerged. A significant number of participants did not believe that discharge planning occurred in critical care, and therefore, thought that they could not provide a definition. There was uncertainty as to what the discharge planning process actually referred to in terms of discharge from critical care to the general ward or discharge from the hospital. There was an emphasis on movement of the patient to the general ward, which was considered in three main ways by first, getting the patient ready for transfer; second, ensuring a smooth transition to the ward and third, transfer of the patient to the ward often occurred because the critical care bed was needed for another patient.

CONCLUSION

The findings presented here suggest at a nursing level, the discharge planning process is not well understood and some degree of mutual exclusivity still remains. There is a need for further education of critical care nurses with regard to the underlying principles of the discharge planning process.

The Royal North Shore Hospital ICU nurse initiated telephone follow up service

The intensive care follow up telephone service has been in progress since July 2001. The aims of the service are to offer former patients an opportunity to explore the intensive care experience and provide support during the recovery phase. Patient experiences vary during recovery but include physical fatigue, sleep disturbances and financial difficulties. Patients who have been telephoned say they are grateful for the opportunity to talk about their experience, say thank you and receive general health related information about diet and exercise. The nurses who have participated in the service have enjoyed greater work satisfaction related to exposure to the patients who are recovering. It offers an opportunity to complete the episode of care. In addition we have been able to feed back patients' suggestions into existing quality frameworks. The information received from former patients has assisted in the development of a home based physical rehabilitation programme, which will be evaluated using a randomised control trial. The follow up service positively contributes to patient outcomes and the positive profile of critical care nursing in the community.

Returning home after intensive care: a comparison of symptoms of anxiety and depression in ICU and elective cardiac surgery patients and their relatives

OBJECTIVE

This study gathered data on symptoms of anxiety and depression in patients and relatives after discharge from intensive care and examined whether the intensive care population differ from an elective cardiac surgery group with regards to their anxiety and depression symptom reporting.

DESIGN AND SETTING

A single measurement point matched group comparison study in an ICU follow-up programme.

PATIENTS AND PARTICIPANTS

Twenty ICU patients and their relatives and a matched comparison group of 15 elective cardiac surgery patients and their relatives.

MEASUREMENTS AND RESULTS

Patients and relatives completed the Hospital Anxiety and Depression Scale. Relatives answered an open question to explore the perceived impact of Intensive care/cardiac surgery on their lives. ICU patients' relatives reported significantly higher number of symptoms of anxiety than did ICU patients, higher number of symptoms of depression than cardiac surgery patients' relatives, and more troubling and life-altering experiences than the relatives of cardiac surgery patients.

CONCLUSIONS

Relatives of ICU patients also suffer anxiety and depression, and services should address this need. Group differences suggest that ICU patients' relatives have "unique" characteristics of depression symptom reporting.

Family carers of ICU survivors: a survey of the burden they experience

Intensive care unit (ICU) survivors may experience deterioration in their quality of life for months following their return home, with families assuming a caregiving role. The aim of this study was to measure the burden associated with caring for a family member who had been critically ill. The study also sought to describe the relationship between three factors (filial obligation, social support, self-efficacy) and caregiver burden. Seventy-one family carers, 51 females (72%) and 20 (28%) males of long-term intensive care patients completed a mailed survey, after signing an informed consent form. Although the vast majority of the caregivers were providing substantial number of hours of care each week, they scored lower than the midpoint on all caregiver burden inventory subscales. Filial obligation was found to be positively associated with caregiver burden; however, there was no association between social support, self-efficacy and caregiver burden. Male caregivers experienced significantly more burden than female caregivers. The findings suggest that an understanding of the factors that impact on caregiver burden of families of ICU survivors is only beginning to emerge.

Following the path of ICU survivors: a quality-improvement activity

Recent interest in continuity of care has meant that the illness trajectory experienced by intensive care unit (ICU) patients has received more attention. Using continuous quality improvement as a framework, this paper describes information obtained during a 3-year period relating to ICU patients' long-term experiences after being discharged from hospital. This information identified that most participants had been discharged home but that many experienced problems with mobility, disability and fatigue. Changes in employment status and the need for financial assistance were noted. As a result of the information provided by this activity, clinical practice has changed and a number of formal research studies have been undertaken.

Developing and evaluating critical care follow-up

The effects of critical illness not only affect the patient and relative during the intensive care stay but often affect for a considerable time afterwards. A growing body of opinion and evidence suggests that many of the needs of those who have been critically ill can be met through critical care follow-up services. A growing number of follow-up services now exist. Their establishment, development and evaluation pose significant challenges for those involved. This paper describes Bassetlaw hospital's critical care follow-up service, how it was established and what an elementary service evaluation project has shown. The findings and experiences are compared with others in published literature, and the paper may be of interest to those who are currently involved in follow-up or who plan to develop such services in the future.

Six-month neuropsychological outcome of medical intensive care unit patients

OBJECTIVE

To examine neuropsychological function, depression, and quality of life 6 months after discharge in patients who received mechanical ventilation in the intensive care unit.

DESIGN

Prospective cohort study.

SETTING

Tertiary care, medical and coronary intensive care unit of a university-based medical center.

STUDY POPULATION

A total of 275 consecutive, mechanically ventilated patients from a medical intensive care unit were prospectively followed. At 6 months, 157 were alive, of whom 41 (26%) returned for extensive follow-up testing.

MEASUREMENT AND MAIN RESULTS

Neuropsychological testing and assessment of depression and quality of life were performed at 6-month follow-up. Seven of 41 patients were excluded from further analysis due to preexisting cognitive impairment determined via surrogate interviews using the Modified Blessed Dementia Rating Scale and a review of medical records. On the basis of strict criteria derived from normative data, we found that 11 of 34 patients (32%) were neuropsychologically impaired. Impairment was generally diffuse but occurred primarily in areas of psychomotor speed, visual and working memory, verbal fluency, and visuo-construction. The rate of neuropsychological deficits in the study population was markedly higher than population norms for mild dementia. Scores on the Geriatric Depression Scale-Short Form were significantly more abnormal in the neuropsychologically impaired group than in the nonimpaired group at hospital discharge (p =.04) and at 6-month follow-up (p =.02), and clinically significant depression was found in 27% of impaired subjects at hospital discharge and in 36% at 6-month follow-up. No differences were observed between groups in quality of life as measured with the Short Form Health Survey-12 at discharge or 6-month follow-up.

CONCLUSIONS

Prolonged neuropsychological impairment is common among survivors of the medical intensive care unit and occurs with greater than anticipated frequency when compared with relevant normative data. Future investigations are warranted to elucidate the nature of the association between critical illness, neuropsychological impairment, depression, and decreased quality of life.

Patient recollection of airway suctioning in the ICU: routine versus a minimally invasive procedure

OBJECTIVE

Many patients have an unpleasant recollection of routine endotracheal suctioning after discharge from the Intensive Care Unit (ICU). We hypothesized that through minimally invasive airway suctioning discomfort and stress may be prevented, resulting in less recollection.

DESIGN

A prospective randomized clinical trial.

SETTING

Two ICUs at the University Hospital of Groningen, the Netherlands.

PATIENTS AND PARTICIPANTS

Adult patients with an intubation period exceeding 24 h were included.

INTERVENTIONS

Patients received either routine endotracheal suctioning (RES) or minimally invasive airway suctioning (MIAS) during the duration of intubation.

MEASUREMENTS AND RESULTS

Within 3 days after ICU discharge all patients were interviewed, regarding recollection and discomfort of suctioning. The level of discomfort was quantified on a visual analogue scale (VAS). We analyzed data from 208 patients (RES: n=113, and MIAS: n=95). A significantly lower prevalence of recollection of airway suctioning was found in the MIAS group (20%) compared to the RES group (41%) (P-value =0.001). No significant difference in level of discomfort was found between the RES and the MIAS group (P-value =0.136).

CONCLUSIONS

Minimally invasive airway suctioning results in a lower prevalence of recollection of airway suction than in RES, but not in discomfort.

Leaving the intensive care unit: a phenomenological study of the patients’ experience

Discharge from intensive care (ICU), is said to pose difficulties for patients; a phenomenon referred to as "relocation stress". However, this phenomenon has not been fully examined, particularly from the critical care patients' perspective. This study, therefore, explored the lived experience of transfer from ICU to the ward. Phenomenology, based on the interpretative Heideggerian approach was used to guide the study. A purposive sample of six participants was selected. Open interviews were used to collect data. Participants were interviewed twice; once in ICU, prior to transfer, and once in the ward following transfer. The findings revealed that pre-transfer, participants were mainly accepting of their impending transfer. Participants discussed a desire for normality and identified that leaving the ICU staff was the most negative component of transfer. In the post-transfer period, findings revealed mixed feelings regarding the actual transfer. Participants were still suffering from physical complaints, which led to feelings of despondency. Differences between ICU and the ward were also highlighted. Finally, the enormity of the ICU experience appeared to have an impact post-transfer. The results of this study indicate that transfer from ICU can be problematic for some individuals. However, caution is required regarding the use of the nursing diagnosis of relocation stress without obtaining an individual perspective on experiences. Recommendations include the need for greater continuity of care for those recovering from critical illness.

Psycho-affective disorder in intensive care units: a review

This paper reviews the literature related to the Intensive Care Unit (ICU) Syndrome. The intention of the paper is to explore the range of psychotic and affective phenomena that may be observed in practice, together with the management of contributory stressors. Patients experience a range of psycho-affective disturbances that may be triggered by drugs, the environment, dehumanizing practices and sleep deprivation. Symptoms do not always disappear following discharge and further research is required to determine the long-term psychological effects of an ICU. Comprehensive assessment of the patient's psychological state, using an appropriate tool, is necessary and should form an integral part of ongoing care. Interventions identified include eradication of dehumanizing behaviour, modification of environmental stimuli, effective communication and therapeutic touch. Where possible, communication needs should be addressed prior to admission, and patients and their families prepared for the unfamiliar world of the ICU.