Screening and treatment of problems after intensive care: a descriptive study of multidisciplinary follow-up

Clinicians' knowledge and understanding regarding multidisciplinary treatment implementation: a study in municipal public class III grade A hospitals in Southwest China

BACKGROUND

Previous studies have highlighted several problems in the implementation of multidisciplinary treatment (MDT) from a managerial perspective. However, no study has addressed these issues from clinicians' perspective. Therefore, this study aimed to identify and address the existing problems in MDT by investigating what clinicians know and think about the implementation of MDT.

METHODS

A self-designed questionnaire was used to evaluate clinicians' understanding of MDT in municipal public Class III Grade A hospitals in Western China using a cross-sectional questionnaire study.

RESULTS

Overall, 70.56% of clinicians knew the scope of MDT, and 63.41% knew the process of MDT. Professional title (P = 0.001; OR: 2.984; 95% CI: 1.590-5.603), participated in MDT (P = 0.017; OR: 1.748; 95% CI: 1.103-2.770), and application for MDT (P = 0.000; OR: 2.442; 95% CI: 1.557-3.830) had an impact on clinicians' understanding of the scope of MDT. Professional title (P = 0.002; OR:2.446; 95% CI: 1.399-4.277) and participation in MDT (P = 0.000; OR: 2.414; 95% CI: 1.581-3.684) influenced clinicians' understanding of the scope of MDT. More than 70% of the respondents thought that MDT was important in medical care. However, less than half of the clinicians who had attended MDT were currently satisfied with the results of MDT.

CONCLUSION

Most clinicians agreed that MDT was crucial in clinical care. However, more than a third of clinicians did not fully understand the scope and process of MDT. Appropriate measures are necessary to improve the quality of MDT. Our study suggests that healthcare administration should strengthen MDT education, especially for new and young clinicians.

Organization, feasibility and patient appreciation of a follow-up consultation in surgical critically ill patients with favorable baseline quality of life and prolonged ICU-stay: a pilot study

OBJECTIVES

Intensive care unit (ICU) survivors are often left with impairments in physical, mental and cognitive functioning (Post-Intensive Care Syndrome (PICS)). We evaluated the organization, the feasibility for caregivers and patients and the patients' appreciation of a post-ICU consultation aiming to detect these PICS-symptoms.

METHODS

A single-center prospective observational pilot study was conducted during an 18 month-period in the surgical ICU of a tertiary care hospital. Consecutive adult patients with an ICU-stay of ≥8 days and a favorable baseline quality of life (utility index ≥0.6 on EQ-5D-3 L) were eligible for inclusion. A post-ICU follow-up consultation consisting of a structured interview was scheduled 3 months after hospital discharge. Characteristics of the consultation (CG) and no consultation group (NCG) were compared. P-values <0.05 were considered significant.

RESULTS

Of 133 eligible patients, 85 (64%) consented for the study and 42 (49%) attended the consultation. A total of 148 phone calls were made to schedule the consultations. Consultations took a median of 68 (61-74) minutes. Compared to CG-patients, NCG-patients were more often discharged to a care facility (P = 0.003) and had more problems with mobility (P = 0.014), self-care (P < 0.001) and usual activities (P = 0.005) after 3 months. At least one PICS-related problem was documented in all patients in the CG and NCG. Thirty-four CG-patients (81%) appreciated the initiative.

CONCLUSION

Organizing an ICU-follow-up consultation was difficult and feasibility was low, but most attending patients appreciated the initiative. Better developed structures for ICU-follow-up are needed in view of the high number of PICS-related problems documented.

Influence on Depression, Anxiety, and Satisfaction of the Relatives' Visit to Intensive Care Units prior to Hospital Admission for Elective Cardiac Surgery: A Randomized Clinical Trial

BACKGROUND

Intensive care units (ICUs) may produce stress on the relatives of patients that have long-term physiological and psychological implications.

OBJECTIVES

This study aimed to evaluate the effects of the relatives´ visit prior to hospital admission(s) on the patient's scheduled cardiac surgery regarding depression, anxiety, and satisfaction of the patient's family in an ICU.

METHODS

A randomized clinical trial [NCT03605420] was carried out according to the CONSORT criteria. Thirty-eight relatives of ICU patients were recruited at an ICU and randomized into study groups. Experimental group participants (n = 19) consisted of relatives who received 1 ICU visit prior to the patient's admission. Control group participants (n = 19) consisted of patients' relatives who received standard care alone. A self-report test battery, including the Impact of Event Scale-Revised (IES-R) and the Hospital Anxiety and Depression Scale (HADS), was completed by the patient's relative prior to the patient's ICU admission and again three and 90 days after ICU discharge. Furthermore, the Family Satisfaction with Care in the Intensive Care Unit (FS-ICU) and Critical Care Family Needs Inventory (CCFNI) were administered to help determine the respondents' satisfaction three days after the patient's ICU discharge.

RESULTS

Statistically significant differences in FS-ICU results were found between control and experimental groups; no statistically significant differences were found in IES-R, HADS, and CCFNI results. Thus, members in the control group were more satisfied with the time elapsed to raise their concerns (p=0.005), emotional support provided (p=0.020), quality of care (p=0.035), opportunities to express concerns and ask questions (p=0.005), and general satisfaction with the ICU's decision-making (p=0.003).

CONCLUSIONS

Relatives' satisfaction during patients' ICU admission may be impaired after their prior visit to the hospital admission. Relative's anxiety and depression scores did not seem to be significantly affected. Relatives´ visit prior to elective cardiac surgery hospital admission impaired their satisfaction in an ICU and may not be advisable for healthcare practice.

Factors and health-related quality of life associated with participation in a post-ICU follow-up. A register study

BACKGROUND

Follow-up for heterogeneous intensive care patients presents challenges for rehabilitation interventions and outcome measurements. The aim was to describe and explore characteristics and determinants for visiting/not visiting a nurse-led clinic (NLC) at different time-points, and to describe physical and mental health (HRQoL) over time.

METHODS

Patients with a length of stay (LOS) of ≥72 hours, discharged from a general intensive care unit 2004-2014, who participated in a 6-month follow-up programme offering visits to NLC at 2 and 6 months were included. The register study includes information regarding patients' participation in NLC, clinical and demographic data from the Patient Administrative System within Intensive care, and data on 2-, 6- and 12-month HRQoL by using SF-36 from the Swedish Intensive Care Registry.

RESULTS

Of 656 patients, 57% visited the NLC on some occasion. These patients were younger (P = .000), had lower Simplified Acute Physiology scores (P = .001) and higher SF-36 physical health domain scores at 2 months (P < .05) compared to those not visiting at all. Visitors at 2 months only were younger, had shorter LOS and higher physical and mental domain scores than patients visiting at 6 months only. Patients visiting the NLC scored significantly higher in all domains from 2 to 12 months, whereas non-visiting-patients' did this in four out of eight domains during the same time frame.

CONCLUSION

Individual patient's characteristics and current health conditions seem to influence visits to NLC or not. The findings may contribute to the development of existing routines to match the diversity of patients' needs and life situations.

Patients' and relatives' experiences of post-ICU everyday life: A qualitative study

BACKGROUND

As advancements in intensive care treatment have resulted in decreased mortality rates, more attention has been given to the experience of life after critical illness. Despite an increase in literature describing the physical, psychological, and cognitive health problems arising after critical illness, there is a shortage of research exploring the lifeworld of patients and relatives, including its internal and external interplay in everyday life. Addressing this is essential for gaining insights into the experience of everyday life and recovery after critical illness.

AIMS AND OBJECTIVES

To explore patients' and relatives' experiences of everyday life after critical illness.

DESIGN

Data were collected using semi-structured interviews with 7 relatives and 12 patients. Interviews were audiotaped and transcribed verbatim.

METHODS

Drawing on the phenomenological-hermeneutic tradition, data were analysed using Ricoeur's theory of interpretation, as described by Dreyer and Pedersen.

FINDINGS

The lifeworld of everyday life was disclosed in the theme "Finding oneself after critical illness," described as an overall comprehensive understanding. This theme was divided into the subthemes (a) redefining the self, (b) reintegrating with family, and (c) resuming everyday life, which followed the trajectory of the three phases: the known past, the uncertain present, and the unknown future.

CONCLUSION

Critical illness and physical, psychological, and cognitive health problems create new and emerging difficulties in patients' and relatives' experiences of everyday life after intensive care. These experiences affect their understanding of themselves, their families, and their ability to resume pre-intensive care unit everyday life.

IMPLICATIONS FOR PRACTICE

The study underlines the need to supplement the affirmed domains in post-intensive care syndrome with a social domain to enhance family-centred care within the intensive care unit and across sectoral borders. Additionally, it highlights the need to develop rehabilitation strategies aimed at patients' and relatives' multifactorial health problems.

The burden of implementation: A mixed methods study on barriers to an ICU follow-up program

PURPOSE

It has been suggested that ICU follow-up clinics can offer support for ICU survivors and their relatives. However, implementation of such clinics can be challenging. We explored the barriers to implementation of an ICU follow-up program from the healthcare providers' perspective.

METHODS

This was a mixed methods study with a triangulation design conducted over the 7-month pilot period of an ICU follow-up program.

RESULTS

The quantitative analysis showed that two main tasks within the program took the most time to be completed: training and tracking. Training new healthcare professionals to acquire the necessary competences for the follow-up clinic was the most time-consuming task [30 min (IQR 13-56)]. Tracking patients, which consists of keeping records of a patient during the hospital stay and when discharged, was the second most time-consuming task [15 min (IQR 10-20)]. We recorded 291 items of qualitative data from the 12 team members who participated. The qualitative analysis identified three domains that were crucial barriers for program implementation: Luhr et al. (2019) [1] organization (37.1%), Máca et al. (2017) [2] engagement (38.5%), and (Gayat et al., 2018 [3]) resources (24%). In agreement with the quantitative data, training and tracking were perceived by participants as laborious tasks and key barriers to implementation of the ICU follow-up program. Despite the expectation that resources would be the most important barrier, they were not considered as such by our participants being only mentioned in 13.4% of our qualitative reports; when mentioned, this barrier was related mostly to insufficient numbers of staff members.

CONCLUSIONS

Awareness of those barriers can help healthcare providers and ICU managers in developing strategies adapted to overcome constraints, thus facilitating the implementation process.

Older patients' recovery following intensive care: A follow-up study with the RAIN questionnaire

The aim was to investigate older patient recovery (65 years+) up to two years following discharge from an intensive care unit (ICU) using the Recovery After Intensive Care (RAIN) instrument and to correlate RAIN with the Hospital Anxiety and Depression Scale (HAD).

METHODS

An explorative and descriptive longitudinal design was used. Eighty-two patients answered RAIN and HAD at least twice following discharge. Demographic and clinical data were collected from patient records.

RESULTS

Recovery after the ICU was relatively stable and good for older patients at the four data collection points. There was little variation on the RAIN subscales over time. The greatest recovery improvement was found in existential ruminations from 2 to 24 months. A patient that could look forward and those with supportive relatives had the highest scores at all four measurements. Having lower financial situation was correlated to poorer recovery and was significant at 24 months. The RAIN and HAD instruments showed significant correlations, except for the revaluation of life subscale, which is not an aspect in HAD.

CONCLUSION

The RAIN instrument shows to be a good measurement for all dimensions of recovery, including existential dimensions, which are not covered by any other instrument.

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.

Validation of the Scale of Psychological Evaluation Specific to Intensive Therapy (IPAT) on a Population of Patients in Romania Admitted to Intensive Care Units

Objective

Through this study, we want to see to what extent the stress is present among the patients admitted in the intensive care units of the Fundeni Clinical Institute of Bucharest, outlining intervention strategies both individually and collectively and validating the psychological evaluation tool (IPAT) specific to the anesthesia and intensive care units in our population.

Method

Intensive Psychological Assessment Tool (IPAT) with 10 items was used for stress assessment in the intensive care unit and Hospital Anxiety Depression Scale (HADS) with 14 items and two subscales, one for anxiety (7 items) and one for depression (7 items).

Conclusion

The study demonstrates the validity of IPAT scale for the patients participating in the study; the results of the study provide the specialists in anesthesia and intensive care units directions to identify elements of stress, anxiety and depression - directions that can improve their daily work, communication with patients and possibly a better quality of life for all involved in the care of a patient.

Results

The results of the study provide the specialists in anesthesia and intensive care units the directions to improve their daily work and possibly a better quality of life for all involved in the care of a patient.

Post-Intensive-Care Syndrome for the Pediatric Neurologist

The number of children who survive critical illness has steadily increased. However, lower mortality rates have resulted in a proportional increase in post-intensive-care morbidity. Critical illness in childhood affects a child's development, cognition, and family functioning. The constellation of physical, emotional, cognitive, and psychosocial symptoms that begin in the intensive care unit and continue after discharge has recently been termed post-intensive-care syndrome. A conceptual model of the post-intensive-care syndrome experienced by children who survive critical illness, their siblings, and parents has been coined post-intensive-care syndrome in pediatrics. Owing to their prolonged hospitalizations, the use of sedative medications, and the nature of their illness, children with primary neurological injury are among those at the highest risk for post-intensive-care syndrome in pediatrics. The pediatric neurologist participates in the care of children with acute brain injury throughout their hospitalization and remains involved after the patient leaves the hospital. Hence it is important for pediatric neurologists to become versed in the early recognition and management of post-intensive-care syndrome in pediatrics. In this review, we discuss the current knowledge regarding post-intensive-care syndrome in pediatrics and its risk factors. We also discuss our experience establishing Pediatric Neurocritical Care Recovery Programs at two large academic centers. Last, we provide a battery of validated tests to identify and manage the different aspects of post-intensive-care syndrome in pediatrics, which have been successfully implemented at our institutions. Dissemination of this "road map" may assist others interested in establishing recovery programs, therefore mitigating the burden of post-intensive-care morbidity in children.

Intensive Care Unit Delirium, Clinical Observations, and Patients' Statements: A Case Study

BACKGROUND

In clinical practice, nurses use their clinical gaze and make observations in order to assess patients' medical conditions and care needs. However, signs of developing intensive care unit delirium (ICUD) are often difficult to determine, as communication with patients is usually limited because of intubation and the seriousness of their medical condition(s). Usually, ICUD is screened and diagnosed with different, mainly nonverbal instruments, which presupposes that the observer is skilled and experienced in recognizing symptoms and signs of delirium.

OBJECTIVES

The objectives were to investigate if there was a concordance between data from continuous clinical observations described in the researcher's logbook and patients' statements of their experiences of delirium during their ICU stay.

METHODS

Inclusion criteria were that the patients had been mechanically ventilated and had stayed in the ICU for a minimum of 36 hours. From this, a multiple-case design (n = 19), based on 1 to 3 hours of observations in the ICU and 2 interviews, was used. The first interview was conducted at the hospital approximately 6 to 14 days after discharge from the ICU, and the second, 4 to 8 weeks following the first interview in patients' homes. Two typical cases were identified and described by a cross-case procedure.

RESULTS

A concordance between observations and patients' statements was found. Subtle, as well as obvious, signs of delirium were possible to detect by attentive observations over time and listening to what patients were trying to convey with their speech and body language. Experiencing delirium seemed to indicate existential suffering where the abnormal became the normal and not being able to distinguish between reality and fantasies.

CONCLUSION

A continuity of skilled observations and listening to patients' statements are vital for detection of ongoing ICU delirium or experiences of delirium.

Avaliação psicológica de pacientes após a alta da unidade de terapia intensiva

A maioria dos pacientes sobrevive ao episódio de doença crítica, contudo, muitos deles podem desenvolver alterações psicológicas após a alta desta unidade. Dada a natureza dos cuidados intensivos e as condições clínicas da maioria dos pacientes esta pesquisa tem como objetivo descrever os resultados da avaliação psicológica de pacientes três meses após a alta dos cuidados críticos. Foram avaliados 160 pacientes, no entanto, devido ao comprometimento neurológico apenas 137 conseguiram responder à avaliação psicológica. Os instrumentos utilizados foram: Planilha para coleta de dados do prontuário, instrumento de avaliação de memórias de UTI, Impact of Event Scale-Revised (IES-R) e Escala Hospitalar de Ansiedade e Depressão (HADS). Os resultados revelaram que a identificação precoce das complicações inerentes ao tratamento crítico poderá trazer benefícios para a prevenção de alterações emocionais/físicas crônicas subsequentes.

Six-Minute Walk Distance After Critical Illness: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Impaired physical functioning is common and long lasting after an intensive care unit (ICU) admission. The 6-minute walk test (6MWT) is a validated and widely used test of functional capacity. This systematic review synthesizes existing data in order to: (1) evaluate 6-minute walk distance (6MWD) in meters over longitudinal follow-up after critical illness, (2) compare 6MWD between acute respiratory distress syndrome (ARDS) versus non-ARDS survivors, and (3) evaluate patient- and ICU-related factors associated with 6MWD.

DATA SOURCES

Five databases (PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature, PsychINFO, and Cochrane Controlled Trials Registry) were searched to identify studies reporting 6MWT after hospital discharge in survivors from general (ie, nonspeciality) ICUs. The last search was run on February 14, 2018. Databases were accessed via Johns Hopkins University Library.

DATA EXTRACTION AND SYNTHESIS

Pooled mean 6MWD were reported, with separate linear random effects models used to evaluate associations of 6MWD with ARDS status, and patient- and ICU-related variables. Twenty-six eligible articles on 16 unique participant groups were included. The pooled mean (95% confidence interval [CI]) 6MWD results at 3- and 12-months post discharge were 361 (321-401) and 436 (391-481) meters, respectively. There was a significant increase in 6MWD at 12 months compared to 3 months (P = .017). In ARDS versus non-ARDS survivors, the mean (95% CI) 6MWD difference over 3-, 6-, and 12-month follow-up was 73 [13-133] meters lower. Female sex and preexisting comorbidity also were significantly associated with lower 6MWD, with ICU-related variables having no consistent associations.

CONCLUSIONS

Compared to initial assessment at 3 months, significant improvement in 6MWD was reported at 12 months. Female sex, preexisting comorbidity, and ARDS (vs non-ARDS) were associated with lower 6MWT results. Such factors warrant consideration in the design of clinical research studies and in the interpretation of patient status using the 6MWT.

Post-traumatic stress symptoms and sense of coherence in proximity to intensive care unit discharge

BACKGROUND

Post-traumatic stress (PTS) symptoms following intensive care unit (ICU) treatment can lead to post-traumatic stress disorder and represent a severe health burden. In trauma patients, a strong sense of coherence (SOC) is associated with fewer PTS symptoms. However, this association has not been investigated in a general ICU sample.

AIMS AND OBJECTIVES

To examine the occurrence of PTS symptoms in general ICU patients early after ICU discharge and to assess possible associations between PTS symptoms and SOC, ICU memory, pain, and demographic and clinical characteristics.

DESIGN

This was a cross-sectional study.

METHODS

Adult patients aged ≥18 years admitted for ≥24 hours to five ICUs between 2014 and 2016 were recruited. PTS symptoms and SOC were measured at the ward within the first week after discharge from the ICU using the Posttraumatic Stress Scale-10 and Sense of Coherence Scale-13. Multiple linear regression analysis was used to identify associations between PTS symptoms and SOC and the selected independent variables.

RESULTS

A total of 523 patients were included (17.8% trauma patients; median age 57 years [range 18-94]; 53.3% male). The prevalence of clinically significant PTS symptoms was 32%. After adjustments for gender and age, lower SOC (P < 0.001), more ICU delusional memories (P < 0.001), greater pain interference (P < 0.001), not being a trauma patient (P = 0.02), and younger age (P = 0.03) were significantly associated with more PTS symptoms.

CONCLUSIONS

One third of patients experienced clinically relevant PTS symptoms early after discharge from the ICU. In the present study, SOC, delusional memory, pain interference, younger age, and not being a trauma patient were factors associated with more PTS symptoms.

RELEVANCE TO CLINICAL PRACTICE

Early individual follow up after ICU discharge focusing on pain relief and delusional memory may reduce PTS symptoms, with a potential of improving rehabilitation.

Effects of a visit prior to hospital admission on anxiety, depression and satisfaction of patients in an intensive care unit

OBJECTIVES

To assess the effects of a vists prior to hospital admission on anxiety, depression and satisfaction of patients admitted electively to an intensive care unit (ICU).

DESIGN

A randomised clinical trial [NCT03605407].

SETTING

A sample of 38 patients was recruited who were to be electively admiited to ICU divided into experimental (n = 19 patients receiving one visit prior to hospital ICU admission for surgery) and control (n = 19 patients not receiving a visit prior to hospital ICU admission for surgery) groups.

MAIN OUTCOME MEASUREMENTS

Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale-Revised (IES-R) were self-reported by patients before ICU admission, at 3-days and 90-days after ICU discharge. Critical Care Family Needs Inventory (CCFNI) and Family Satisfaction with Care in the Intensive Care Unit (FS-ICU) were used to measure the users' satisfaction before ICU admission and 3-days after ICU discharge.

RESULTS

There were statistically significant differences between experimental and control groups for FS-ICU, but not for HADS, IES-R and CCFNI. Indeed, control group patients were more satisfied with regard to emotional support, ease of getting information, control feeling, concerns and questions expression ability and overall score for decision-making satisfaction.

CONCLUSIONS

The visit prior to hospital admission did not seem to modify anxiety or depression, but may impair satisfaction of ICU patients.

Comprehensive care of ICU survivors: Development and implementation of an ICU recovery center

PURPOSE

To describe the design and initial implementation of an Intensive Care Unit Recovery Center (ICU-RC) in the United States.

MATERIALS AND METHODS

A prospective, observational feasibility study was undertaken at an academic hospital between July 2012 and December 2015. Clinical criteria were used to develop the ICU-RC, identify patients at high risk for post intensive care syndrome (PICS), and offer them post-ICU care.

RESULTS

218/307 referred patients (71%) survived to hospital discharge; 62 (28% of survivors) were seen in clinic. Median time from discharge to ICU-RC visit was 29days. At initial evaluation, 64% of patients had clinically meaningful cognitive impairment. Anxiety and depression were present in 37% and 27% of patients, respectively. One in three patients was unable to ambulate independently; median 6min walk distance was 56% predicted. Of 47 previously working patients, 7 (15%) had returned to work. Case management and referral services were provided 142 times. The median number of interventions per patient was 4.

CONCLUSIONS

An ICU-RC identified a high prevalence of cognitive impairment, anxiety, depression, physical debility, lifestyle changes, and medication-related problems warranting intervention. Whether an ICU-RC can improve ICU recovery in the US should be investigated in a systematic way.

Determinants of Quality of Life and Return to Work Following Acute Respiratory Distress Syndrome

BACKGROUND

Acute respiratory distress syndrome (ARDS) in adults is a consequence of lung damage caused by either pulmonary or extrapulmonary disease. Survivors often suffer from an impaired health-related quality of life (HRQoL), mental and physical impairments, and persistent inability to work.

METHODS

In this systematic review of the literature, we consider the determinants of HRQoL and return to work (RtW). 24 observational studies showing a statistical association between one or more determinants and HRQoL or RtW were included. Because of the heterogeneity of these studies, no statistical aggregation of the individual effect estimates was carried out; instead, the results are summarized descriptively.

RESULTS

Psychopathological manifestations, in particular, are associated with impaired quality of life. In contrast, many care- and disease-related determinants had only small, non-significant effects on HRQoL and RtW. The onesecond capacity was found in all studies to be positively associated with the HRQoL. ARDS induced by sepsis seems to be a risk factor for a lower HRQoL in comparison to ARDS of other causes. A synthesis of the evidence is impeded both by the high level of heterogeneity of studies and by the high risk of selection bias in all studies.

CONCLUSION

The identification of determinants of impaired quality of life after ARDS is essential for the assessment of clinically relevant interventions. In multiple studies, major significant effects were only observed when determinants the content of which was closely related to the scales of the HRQoL instruments were measured at the same time as the HRQoL.

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.

The provision of nurse-led follow-up at Norwegian intensive care units

AIMS AND OBJECTIVES

To describe the prevalence, content and administration of intensive care unit diaries and follow-up practices offered to patients and their families in Norway.

BACKGROUND

Intensive care treatment has been associated with risks for new or increased health impairments affecting both patients and their families. These impairments have the potential of continuing beyond the acute phase of treatment. In parallel, preventive actions have gradually become an integrated part of critical care nursing, and in Norway, national recommendations for the use of intensive care unit diaries have been established.

DESIGN AND METHODS

A survey was conducted in Norwegian intensive care units offering care for adult patients, using a questionnaire asking about the frequency, administration and content of the follow-up offered to patients, their relatives, as well as bereaved family members.

RESULTS

Thirty-nine of 66 (59.1%) invited intensive care units answered the questionnaire. The majority (n = 33, 84.6%) of the responding units had follow-up routines. The provision of diaries was the most frequent follow-up activity (n = 24, 61.5%), and consultations postdischarge formed an integrated part of the diary practice. Consultations with bereaved were conducted in 21 (53.8%) of the intensive care units. About one quarter of the responding intensive care units had positions for follow-up nursing staff.

CONCLUSION

Nurse-led follow-up after critical care was a common activity in Norwegian intensive care units, comprising diaries and consultations offered to patients and family members. The follow-up was mainly driven by bottom-up processes conducted by dedicated nurses motivated by the patients' and their families' situation and feedback.

RELEVANCE TO CLINICAL PRACTICE

Adherence to recommendations, as well as the availability of defined positions for aftercare nurses or teams, may improve the implementation of follow-up practices and reduce suffering after discharge from Norwegian intensive care units.

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.

Psychological recovery after intensive care: Outcomes of a long-term quasi-experimental study of structured nurse-led follow-up

OBJECTIVES

To compare psychological recovery of patients receiving structured nurse-led follow-up and patients receiving usual care after intensive care discharge.

DESIGN

Quasi-experimental study.

SETTING

Single centre, university hospital, mixed intensive care patient population.

MAIN OUTCOME MEASURES

Symptoms of post-traumatic stress disorder, anxiety and depression measured three and four times over 12 months after intensive care discharge. Disturbing memories of the intensive care stay and psychological reactions (that one's life was in danger, threat to physical integrity, intense fear, helplessness, horror) three months after intensive care. A mixed effect model tested differences between the groups over time and regression model predicted post-traumatic stress at three months.

RESULTS

The experimental group had significantly more symptoms of post-traumatic stress and anxiety than the control group over the 12 months. Patients from both groups had severe symptoms of post-traumatic stress. Patients with post-traumatic stress at three months had disturbing memories and psychological reactions.

CONCLUSION

The structured nurse-led follow-up did not improve patients' measured outcomes of psychological recovery after intensive care. Patients with severe symptoms of post-traumatic stress are of concern. Emphasis needs to be placed on disturbing memories of the intensive care stay and psychological reactions when constructing intensive care nurse-led follow-up.

Critical Care Follow-up Clinics: A Scoping Review of Interventions and Outcomes

OBJECTIVE

The purpose of this scoping review is to identify evidence describing benefits of interventions provided in intensive care unit (ICU) survivor follow-up clinics.

BACKGROUND

Advances in ICU treatments have increased the number of survivors who require specialized care for ICU-related sequelae. Intensive care unit survivor follow-up clinics exist, yet little is known about the nature and impact of interventions provided in such clinics. A scoping review of publications about in-person post-ICU follow-up care was undertaken.

METHOD

Ten databases were searched yielding 111 relevant unique publication titles and abstracts. Sample heterogeneity supported using a scoping review method. After excluding nonrelated publications, 33 reports were fully reviewed. Twenty international publications were included that described ICU follow-up clinic interventions and/or outcomes.

RESULTS

Authors discussed very diverse interventions in 15 publications, and 9 reported some level of intervention effectiveness. Evidence was strongest that supported the use of prospective diaries as an intervention to prevent or improve psychological symptoms, whereas evidence to support implementation of other interventions was weak.

CONCLUSIONS

Although ICU follow-up clinics exist, evidence for interventions and effectiveness of treatments in these clinics remains underexplored.

IMPLICATIONS

Intensive care unit survivor follow-up clinics provide a venue for further interdisciplinary intervention research that could lead to better health outcomes for ICU survivors.

Posttraumatic stress syndrome associated with stays in the intensive care unit: importance of nurses' involvement

More patients in the intensive care unit are surviving their critical illnesses because of advances in medical care. This change in survival has led to an increased awareness of the emotional consequences of being critically ill. Posttraumatic stress disorder has been identified in approximately 9% to 27% of critically ill patients compared with 7% of the general US population. Risk factors such as treatment with mechanical ventilation, sedation, delusional memories, and agitation are associated with development of posttraumatic stress disorder in patients in the intensive care unit. Individuals with posttraumatic stress disorder are more likely to experience negative physical and psychiatric health outcomes and a lower quality of life than are patients without the disorder. Early identification and treatment of patients experiencing these signs and symptoms may reduce these physical and psychological comorbid conditions. Through careful monitoring of medications, early mobilization, sleep promotion, and pain management, nurses may be able to reduce signs and symptoms of posttraumatic stress disorder.

Follow-up visit in an ICU: receiving a sense of coherence

AIM

To describe patients' experiences of a follow-up visit to an intensive care unit (ICU) after being critically ill and nursed there.

BACKGROUND

Knowledge about the follow-up visit needs to be developed, with the previously critically ill patient in focus.

DESIGN

Qualitative descriptive.

METHOD

Semi-structured interviews were conducted with nine patients and analysed using qualitative content analysis. The data collection occurred during spring 2014.

FINDINGS

During the follow-up visits in ICU, the relatives, the patient diary, and those who took part in the care contribute to fill memory gaps to create a picture and an explanation of the care period.

CONCLUSION

The follow-up visit is an important tool in the patients' struggle to create a context and coherence from a missing or unreal time. The patient diary is essential to subsequently be able to relate to the period of care.

RELEVANCE TO CLINICAL PRACTICE

The follow-up visit, together with a personal diary, after an ICU stay could be seen as significant for strengthening the patients' feeling of coherence and better health.

Early prediction of new-onset physical disability after intensive care unit stay: a preliminary instrument

Introduction

Many intensive care unit (ICU) survivors suffer from physical disability for months after ICU stay. There is no structured method to identify patients at risk for such problems. The purpose of the study was to develop a method for early in-ICU prediction of the patient’s individual risk for new-onset physical disability two months after ICU stay.

Methods

In total, 23 potential predictors for physical disability were assessed before individual ICU discharge. Two months after ICU discharge, out of 232 eligible patients, 148 ICU survivors (64%) completed the activity of daily living (ADL) staircase questionnaire to determine new-onset physical disability.

Results

A total of 95% percent of patients had no ADL reduction prior to ICU admission. Forty-seven percent (n = 69) of questionnaire responders suffered from worsened ADL. We identified four independent predictors for new-onset physical disability: Low educational level (odds ratio (OR) = 6.8), impaired core stability (OR = 4.6), fractures (OR = 4.5) and ICU length of stay longer than two days (OR = 2.6). The predictors were included in a screening instrument. The regression coefficient of each predictor was transformed into a risk score. The sum of risk scores was related to a predicted probability for physical disability in the individual patient. The cross-validated area under receiver operating characteristics curve (AUC) for the screening instrument was 0.80.

Conclusions

Educational level is the single most important predictor for new-onset physical disability two months after ICU stay, followed by impaired core stability at ICU discharge, the presence of fractures and ICU stay longer than two days. A simple screening instrument based on these predictors can be used at ICU discharge to determine the risk for new-onset physical disability. This preliminary instrument may help clinicians to identify patients in need of support, but needs external validation prior to wider clinical use.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0455-7) contains supplementary material, which is available to authorized users.

Organizing safe transitions from intensive care

Background. Organizing and performing patient transfers in the continuum of care is part of the work of nurses and other staff of a multiprofessional healthcare team. An understanding of discharge practices is needed in order to ultimate patients' transfers from high technological intensive care units (ICU) to general wards. Aim. To describe, as experienced by intensive care and general ward staff, what strategies could be used when organizing patient's care before, during, and after transfer from intensive care. Method. Interviews of 15 participants were conducted, audio-taped, transcribed verbatim, and analyzed using qualitative content analysis. Results. The results showed that the categories secure, encourage, and collaborate are strategies used in the three phases of the ICU transitional care process. The main category; a safe, interactive rehabilitation process, illustrated how all strategies were characterized by an intention to create and maintain safety during the process. A three-way interaction was described: between staff and patient/families, between team members and involved units, and between patient/family and environment. Discussion/Conclusions. The findings highlight that ICU transitional care implies critical care rehabilitation. Discharge procedures need to be safe and structured and involve collaboration, encouraging support, optimal timing, early mobilization, and a multidiscipline approach.

Rehabilitation activities, out-patient visits and employment in patients and partners the first year after ICU: a descriptive study

OBJECTIVES

To describe the influence of critical illness on patients and their partners in relation to rehabilitation, healthcare consumption and employment during the first year after Intensive Care Unit discharge.

DESIGN

Longitudinal, observational and descriptive.

SETTING

Five Danish Intensive Care Units.

METHODS

Data were collected from hospital charts, population registers and interviews with 18 patients and their partners at 3 and 12 months after intensive care discharge. Descriptive statistical analysis was performed.

RESULTS

Post-discharge inpatient rehabilitation was median (range) 52 (15-174) days (n=10). Community-based training was 12 (3-34) weeks (n=15). Neuropsychological rehabilitation following brain damage was 13-20 weeks (n=3). Number of out-patient visits 1 year before and 1 year after were mean 3 versus 8, and General Practitioner visits were 12 versus 18. Three patients resumed work at pre-hospitalisation employment rates after 12 months. After the patients' stay in intensive care, partners' mean full-time sick leave was 17 (range 0-124) days and 21 (range 0-106) days part time. Partners often had long commutes.

CONCLUSION

Most patients had comprehensive recovery needs requiring months of rehabilitation. Some partners needed extensive sick leave. The study reveals the human cost of critical illness and intensive care for patients and partners in the Danish welfare system.

Post-traumatic stress disorder symptoms after acute lung injury: a 2-year prospective longitudinal study

BACKGROUND

Survivors of critical illnesses often have clinically significant post-traumatic stress disorder (PTSD) symptoms. This study describes the 2-year prevalence and duration of PTSD symptoms after acute lung injury (ALI), and examines patient baseline and critical illness/intensive care-related risk factors.

METHOD

This prospective, longitudinal cohort study recruited patients from 13 intensive care units (ICUs) in four hospitals, with follow-up 3, 6, 12 and 24 months after ALI onset. The outcome of interest was an Impact of Events Scale - Revised (IES-R) mean score ≥1.6 ('PTSD symptoms').

RESULTS

During the 2-year follow-up, 66/186 patients (35%) had PTSD symptoms, with the greatest prevalence by the 3-month follow-up. Fifty-six patients with post-ALI PTSD symptoms survived to the 24-month follow-up, and 35 (62%) of these had PTSD symptoms at the 24-month follow-up; 50% had taken psychiatric medications and 40% had seen a psychiatrist since hospital discharge. Risk/protective factors for PTSD symptoms were pre-ALI depression [hazard odds ratio (OR) 1.96, 95% confidence interval (CI) 1.06-3.64], ICU length of stay (for a doubling of days, OR 1.39, 95% CI 1.06-1.83), proportion of ICU days with sepsis (per decile, OR 1.08, 95% CI 1.00-1.16), high ICU opiate doses (mean morphine equivalent ≥100 mg/day, OR 2.13, 95% CI 1.02-4.42) and proportion of ICU days on opiates (per decile, OR 0.83, 95% CI 0.74-0.94) or corticosteroids (per decile, OR 0.91, 95% CI 0.84-0.99).

CONCLUSIONS

PTSD symptoms are common, long-lasting and associated with psychiatric treatment during the first 2 years after ALI. Risk factors include pre-ALI depression, durations of stay and sepsis in the ICU, and administration of high-dose opiates in the ICU. Protective factors include durations of opiate and corticosteroid administration in the ICU.

Gender differences in psychological morbidity and treatment in intensive care survivors--a cohort study

Introduction

Many hospitals have initiated follow-up to facilitate rehabilitation after critical illness and intensive care, although the efficacy of such an intervention is uncertain. Studies in trauma research indicate significant differences in psychological reactions to traumatic events between men and women. Our aim, in a quasi-experimental design, was to compare psychological morbidity and treatment effects between men and women enrolled in a multidisciplinary intensive care unit (ICU) follow-up programme (follow-up group) and ICU patients not offered such follow-up (control group).

Methods

Men and women treated more than four days in the ICU in 2006, before ICU follow-up started, were compared with men and women treated in 2007 and 2008, when all patients with an ICU stay of more than four days were offered ICU follow-up at 3, 6 and 12 months post-ICU. Fourteen months after ICU discharge, psychological problems were measured with Impact of Event Scale (IES) for posttraumatic stress and Hospital Anxiety and Depression Scale (HADS) for anxiety and depression.

Results

Women with no follow-up reported significantly higher IES scores than men. Women in the follow-up group reported significantly lower IES scores compared to women in the control group, both in crude analysis and after adjusting for significant confounders/predictors (age, ICU length of stay and previous psychological problems). Furthermore, the 75^th percentile for IES and HADS-Depression scores (high scores and degree of symptoms of psychological problems) in women in the follow-up group was lower than in those without follow-up (IES: -17.4 p, P <.01, HADS-depression: -4.9 p, P <.05). For men, no significant differences were found between the no follow-up and the follow-up group.

Conclusion

Psychological problems after critical illness and intensive care appear to be more common in women than in men. A multidisciplinary ICU follow-up may reduce the incidence of long-term symptoms of posttraumatic stress and depression for women.