Intensive care syndrome: a literature review

[Path Analysis for Delirium on Patient Prognosis in Intensive Care Units]

PURPOSE

This study was conducted to investigate relationship between delirium, risk factors on delirium, and patient prognosis based on Donabedian's structure-process-outcome model.

METHODS

This study utilized a path analysis design. We extracted data from the electronic medical records containing delirium screening data. Each five hundred data in a delirium and a non-delirium group were randomly selected from electronic medical records of medical and surgical intensive care patients. Data were analyzed using SPSS 20 and AMOS 24.

RESULTS

In the final model, admission via emergency department (B=.06, p=.019), age over 65 years (B=.11, p=.001), unconsciousness (B=.18, p=.001), dependent activities (B=.12, p=.001), abnormal vital signs (B=.12, p=.001), pressure ulcer risk (B=.12, p=.001), enteral nutrition (B=.12, p=.001), and use of restraint (B=.30, p=.001) directly affecting delirium accounted for 56.0% of delirium cases. Delirium had a direct effect on hospital mortality (B=.06, p=.038), hospital length of stay (B=5.06, p=.010), and discharge to another facility (not home) (B=.12, p=.001), also risk factors on delirium indirectly affected patient prognosis through delirium.

CONCLUSION

The use of interventions to reduce delirium may improve patient prognosis. To improve the dependency activities and risk of pressure ulcers that directly affect delirium, early ambulation is encouraged, and treatment and nursing interventions to remove the ventilator and drainage tube quickly must be provided to minimize the application of restraint. Further, delirium can be prevented and patient prognosis improved through continuous intervention to stimulate cognitive awareness and monitoring of the onset of delirium. This study also discussed the effects of delirium intervention on the prognosis of patients with delirium and future research in this area.

Intelligent ICU for Autonomous Patient Monitoring Using Pervasive Sensing and Deep Learning

Currently, many critical care indices are not captured automatically at a granular level, rather are repetitively assessed by overburdened nurses. In this pilot study, we examined the feasibility of using pervasive sensing technology and artificial intelligence for autonomous and granular monitoring in the Intensive Care Unit (ICU). As an exemplary prevalent condition, we characterized delirious patients and their environment. We used wearable sensors, light and sound sensors, and a camera to collect data on patients and their environment. We analyzed collected data to detect and recognize patient's face, their postures, facial action units and expressions, head pose variation, extremity movements, sound pressure levels, light intensity level, and visitation frequency. We found that facial expressions, functional status entailing extremity movement and postures, and environmental factors including the visitation frequency, light and sound pressure levels at night were significantly different between the delirious and non-delirious patients. Our results showed that granular and autonomous monitoring of critically ill patients and their environment is feasible using a noninvasive system, and we demonstrated its potential for characterizing critical care patients and environmental factors.

Nonvocal Ventilated Patients Perceptions of Being Understood

This metasynthesis presents an enlarged interpretation and understanding of nonvocal mechanically ventilated patients’experiences with communication. Peplau’s interpersonal relations theory provided the theoretical framework for the metasynthesis. The final sample included 12 qualitative studies, for a total of 111 participants. The data, methods, and theoretical frameworks were critically interpreted. Commonthreads detected across study participants’individual experiences were synthesized to form a greater understanding of nonvocal ventilated patients’ perceptions of being understood. Five overarching themes were divided into two groups. The first group of themes was categorized as the characteristics of nonvocal ventilated patients’communication experiences. Nonvocal individuals were often not understood, which resulted in loss of control and negative emotional responses. The second group of themes was categorized as the kind of nursing care desired by nonvocal patients in order to be understood. Nonvocal patients wanted nursing care that was delivered in an individualized, caring manner. This facilitated positive interpersonal relations between the patient and the nurse. Findings are discussed in relation to the current state of knowledge on this topic.

Psychological factors in exceptional, extreme and torturous environments

Our cognitive system has adapted to support goal-directed behaviour within a normal environment. An abnormal environment is one to which we are not optimally adapted but can accommodate through the development of coping strategies. These abnormal environments can be ‘exceptional’, e.g., polar base, space station, submarine, prison, intensive care unit, isolation ward etc.; ‘extreme’, marked by more intense environmental stimuli and a real or perceived lack of control over the situation, e.g., surviving at sea in a life-raft, harsh prison camp etc.; or ‘tortuous’, when specific environmental stimuli are used deliberately against a person in an attempt to undermine his will or resistance. The main factors in an abnormal environment are: psychological (isolation, sensory deprivation, sensory overload, sleep deprivation, temporal disorientation); psychophysiological (thermal, stress positions), and psychosocial (cultural humiliation, sexual degradation). Each single factor may not be considered tortuous, however, if deliberately structured into a systemic cluster may constitute torture under legal definition. The individual experience of extremis can be pathogenic or salutogenic and attempts are being made to capitalise on these positive experiences whilst ameliorating the more negative aspects of living in an abnormal environment.

The role of noise in clinical environments with particular reference to mental health care: A narrative review

BACKGROUND

There is a large literature suggesting that noise can be detrimental to health and numerous policy documents have promoted noise abatement in clinical settings.

OBJECTIVES

This paper documents the role of noise in clinical environments and its deleterious effects with a particular focus on mental health care. Our intention however, is to go beyond the notion that noise is simply undesirable and examine the extent to which researchers have explored the meaning of sound in hospital settings and identify new opportunities for research and practice.

DATA SOURCES AND REVIEW METHODS

This is a narrative review which has grouped the literature and issues in the field into themes concerning the general issues of noise in health care; sleep noise and hospital environments; noise in intensive care units; implications for service users and staff; and suggestions for new ways of conceptualising and researching clinical soundscapes. Data sources comprised relevant UK policy documents and the results of a literature search of Pubmed, Scopus and Web of Knowledge using terms such as noise, health, hospital, soundscape and relevant additional terms derived from the papers retrieved. In addition the references of retrieved articles were scanned for additional relevant material and historical items significant in shaping the field.

RESULTS

Excess unwanted noise can clearly be detrimental to health and impede recovery, and this is clearly recognised by policymakers especially in the UK context. We use the literature surveyed to argue that it is important also to see the noise in clinical environments in terms of the meaning it conveys and rather than merely containing unwanted sound, clinical environments have a 'soundscape'. This comprises noises which convey meaning, for example about the activities of other people, the rhythms of the day and the nature of the auditory community of the hospital. Unwanted sound may have unwanted effects, especially on those who are most vulnerable, yet this does not necessarily mean that silence is the better option. Therefore it is our contention that it is important to begin thinking about the social functions of sound in the mental health environment.

CONCLUSIONS

Whilst it can be stressful, sound can also be soothing, reassuring and a rich source of information about the environment as well. It may be used to secure a degree of privacy for oneself, to exclude others or as a source of solidarity among friends and colleagues. The challenge then is to understand the work that sound does in its ecological context in health care settings.

Stressors in intensive care units in Syria: patients' perceptions

The purpose of this cross-sectional study was to identify the stressors and the level of stress as perceived by hospitalised Syrian patients of intensive care units (ICUs). A convenience sample of 150 Syrians who were hospitalised in ICUs located in the Syrian capital, Damascus, were chosen as study participants and were interviewed using a structured interview guide of the Intensive Care Units Environmental Stressors Scale (ICUESS). The findings revealed that physical stressors were perceived as the most stressful ones, whereas psychological stressors were the least stressful. These findings are congruent with the majority of similarly available regional and international literature. It was also statistically noticed that participants with a higher level of education and income were more sensitive in perceiving the stressors than those who had a lower level of education and income. The findings suggested that nurses must utilise effective measures in ICUs to relieve patients' pain and provide a humane ICU environment and atmosphere in which rest is enabled. In conclusion, decreasing the stress level has a positive impact on patients' health outcomes, where adequate attention to patients' physical and psychological domains should equally be considered.

Neuro-occupation: linking sensory deprivation and self-care in the ICU patient

Neuro-occupation is an emerging concept in occupational therapy. The concept of neuro-occupation provides a basis to understand how the nervous system is intertwined with all aspects of occupational performance. This paper uses the framework of neuro-occupation to link a neurological system, the reticular activating system (RAS), to the performance of self-care by patients in an intensive care setting. This correlation is made because the RAS is responsible for organizing sensory information. Inappropriate amounts of stimulation effect the RAS and result in sensory deprivation or sensory overload, which negatively impacts occupational performance. Implications for occupational therapy practice are also addressed.

Memories from intensive care unit persist for several years--a longitudinal prospective multi-centre study

INTRODUCTION

In connection with the care received in the intensive care unit (ICU), the patient can experience discomfort and frustration. Earlier studies have shown mechanical ventilation (MV) to be a factor that increases patients' delusional memories in the ICU. The patients who need MV after a physical trauma constitute a vulnerable group who so far has attracted little attention from a long-term perspective.

AIM

The aim for this study is to describe mechanically ventilated trauma patients over time regarding their memories, psychological recovery and health related quality of life (HRQoL).

METHODS

In a multicentre study, 41 patients who had received MV, answered a questionnaire with the SF-36, HAD and ICUM tool on two occasions about one and five years after the injury and care in the ICU.

RESULTS

The patients' memories were stable over time and significantly more patients remembered panic and anxiety. 37% remembered pain one year after the trauma and 46% five years thereafter. The majority of the patients remembered the family's presence from their ICU stay. Half of the patients had thoughts regarding why they had so few recollections. One fourth of the patients experienced clear symptoms of anxiety and the same amount had symptoms of depression one year after the injury. In seven of the patients the symptoms of probable anxiety persisted after five years. In six of the patients the symptoms of probable depression persisted after five years. Two of eight dimensions in HRQoL, the physical and emotional role functions, had improved significantly five years after the injury.

CONCLUSIONS

Five years after the trauma, the memories from the ICU were still the same and the HRQoL improved in only two out of eight dimensions. A smaller group of patients had remaining symptoms of psychological ill-health. MV in connection with trauma may result in continued reduced health in the long term.

Adverse events are common on the intensive care unit: results from a structured record review

BACKGROUND

Intensive care is advanced and highly technical, and it is essential that, despite this, patient care remains safe and of high quality. Adverse events (AEs) are supposed to be reported to internal quality control systems by health-care providers, but many are never reported. Patients on the intensive care unit (ICU) are at special risk for AEs. Our aim was to identify the incidence and characteristics of AEs in patients who died on the ICU during a 2-year period.

METHODS

A structured record review according to the Global Trigger Tool (GTT) was used to review charts from patients cared for at the ICU of a middle-sized Swedish hospital during 2007 and 2008 and who died during or immediately after ICU care. All identified AEs were scored according to severity and preventability.

RESULTS

We reviewed 128 records, and 41 different AEs were identified in 25 patients (19.5%). Health care-associated infections, hypoglycaemia, pressure sores and procedural complications were the most common harmful events. Twenty two (54%) of the AEs were classified as being avoidable. Two of the 41 AEs were reported as complications according to the Swedish Intensive Care Registry, and one AE had been reported in the internal AE-reporting system.

CONCLUSION

Almost one fifth of the patients who died on the ICU were subjected to harmful events. GTT has the advantage of identifying more patient injuries caused by AEs than the traditional AE-reporting systems used on many ICUs.

A clinical update on delirium: from early recognition to effective management

Delirium is a neuropsychiatric syndrome characterized by altered consciousness and attention with cognitive, emotional and behavioural symptoms. It is particularly frequent in elderly people with medical or surgical conditions and is associated with adverse outcomes. Predisposing factors render the subject more vulnerable to a congregation of precipitating factors which potentially affect brain function and induce an imbalance in all the major neurotransmitter systems. Early diagnosis of delirium is crucial to improve the prognosis of patients requiring the identification of subtle and fluctuating signs. Increased awareness of clinical staff, particularly nurses, and routine screening of cognitive function with standardized instruments, can be decisive to increase detection rates of delirium. General measures to prevent delirium include the implementation of protocols to systematically identify and minimize all risk factors present in a particular clinical setting. As soon as delirium is recognized, prompt removal of precipitating factors is warranted together with environmental changes and early mobilization of patients. Low doses of haloperidol or olanzapine can be used for brief periods, for the behavioural control of delirium. All of these measures are a part of the multicomponent strategy for prevention and treatment of delirium, in which the nursing care plays a vital role.

Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit

OBJECTIVE

To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements.

DESIGN AND SETTING

A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center.

PATIENTS

A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009.

INTERVENTIONS

None.

MEASUREMENTS

Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria.

RESULTS

A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74-1.0).

CONCLUSIONS

The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.

Muslim women's experiences of suffering in Jordanian intensive care units: a narrative study

This paper explores Muslim women's experiences of suffering in Jordanian intensive care units. A narrative approach was employed to access women's stories of their critical illness. Sixteen women who had spent at least 48 hours in intensive care were recruited from two hospitals in a Jordanian city and took part in between one and three interviews over a six-month period. Women's accounts of suffering were pervaded with physical, social, spiritual and technological themes. Pain was a central strand in the women's accounts and was experienced often as severe, overwhelming and disturbing to their sleep. The sudden onset of illness, the unfamiliar ICU environment and feeling of uncertainty made it difficult for the women to interpret their experiences. Religious beliefs and cultural norms helped the women make sense of their suffering. Social support, especially from the family, was reported by the women to be essential: a lack of social support was seen as a symbol of death. This study emphasises the importance of looking at a patient who is critically ill as a whole person within the context of their cultural, spiritual and biographical milieu.

Patient's self-determination in intensive care-from an action- and confirmation theoretical perspective. The intensive care nurse view

When becoming an intensive care patient life changes dramatically. In order to save life, different actions are performed by the caregivers and the patient's ability to exercise self-determination is non-existent. After the acute phase the patient is more awake and the possibilities for self-determination change. The purpose of this study was to describe intensive care nurses' (ICNs) views of patient's self-determination in an intensive care unit and to systematize ICNs' nursing actions for supporting patient's self-determination from an action- and confirmation-theoretic perspective. In order to answer these questions, 17 interviews with ICNs were conducted by the use of the Critical Incident Technique (CIT). The transcripts were then analysed using a hermeneutic analysis method and structured by the SAUC model for confirming nursing. The main findings were that the ICN thought that the ICU patient's self-determination was low and restricted. It was more common that the ICN acted to strengthen the patient's self-determination in nursing care, but there were no specific nursing goals for patient's self-determination. The most common actions for supporting self-determination were supplying the patient with information and engaging the patient in making a day plan. The nursing implications are that the ICN's view of human being as an acting subject is important for the ICN's awareness to recognise the patient's own personal resources to handle the critically ill situation and that the ICN's competence to manifest qualified nursing is necessary for strengthening patient's self-determination.

Multicentre study of delirium in ICU patients using a simple screening tool

Traditionally, intensive care unit (ICU) delirium was viewed as benign and was under-diagnosed in the absence of ICU-appropriate screening tools. Research suggests that up to half of all ICU patients experiencing delirium will continue to do so after discharge to the ward, and half of those experiencing delirium in the ward will die within 1 year of delirium diagnosis. ICU-specific screening tools are now available. The purpose of this study was to identify the incidence of delirium in ICU and explore its associations to clinical factors and outcomes. A secondary aim was to evaluate the usefulness of the intensive care delirium screening checklist (ICDSC). A total of 185 patients in six ICUs in Australia and New Zealand were screened for delirium using the ICDSC over two 12-hour periods per day for the duration of their ICU admission. Some 84 patients (45%) developed delirium. Development of delirium was associated with increased severity of illness (acute physiology and chronic health evaluation--APACHE II--and sequential organ failure assessment--SOFA), ICU length of stay (LOS), and use of psycho-active drugs. Delirious patients showed no statistically significant difference in ICU and hospital mortality rates, nor prolonged hospital LOS. The ICDSC was found to be user-friendly. The incidence of delirium, observed characteristics and outcomes for patients admitted to Australian and New Zealand ICUs for > 36 hours without any history of altered mental state fell in the mid-range and were generally consistent with previous literature. An ICU-specific delirium assessment, such as the ICDSC, should be included in routine ICU observations to minimise under-diagnosis of this serious phenomenon.

The importance of diagnosing and managing ICU delirium

ICU delirium represents a form of brain dysfunction that in many cohorts has been diagnosed in 60 to 85% of patients receiving mechanical ventilation. This organ dysfunction is grossly underrecognized because a majority of patients have hypoactive or "quiet" delirium characterized by "negative" symptoms (eg, inattention and a flat affect) not alarming the treating team. Hyperactive delirium, formerly called ICU psychosis, stands out because of symptoms such as agitation that may cause harm to self or staff, but is actually rare relative to hypoactive delirium and associated with a better prognosis. Delirium is often incorrectly thought to be transient and of little consequence. After adjusting for numerous covariates, delirium is a strong, independent predictor of prolonged length of stay, reintubation, higher mortality, and cost of care. Expanded work on patient safety and recommendations by professional societies have established the importance of delirium monitoring and recommended it as standard practice in ICUs all over the world. This evidence-based review for physicians, nurses, respiratory therapists, and pharmacists will outline why it is imperative that patients be routinely monitored for delirium. This review will discuss modifiable risk factors for delirium, such as metabolic disturbances or potent sedative and analgesic medications. Attention to mitigating risk factors, along with recommended pharmacologic approaches such as antipsychotic medications, may provide resolution of delirium in some patients, while others will persist with refractory brain dysfunction and long-term cognitive impairment following critical illness.

Patients' experiences of being delirious

AIM

The aim was to describe patients' experiences of being delirious.

BACKGROUND

Delirium is a serious psychiatric disorder that is frequently reported from hospital care settings, particularly among older patients undergoing hip surgery. It involves disturbances of consciousness and changes in cognition, a state which develops over a short period of time and tends to fluctuate during the course of the day. It is a certified fact that delirium is poorly diagnosed and recognized although the state often is described as terrifying. To be able to give professional care, it is of the utmost importance to know more about patients' experience of delirium.

METHOD

Included in the interviews were patients who had undergone hip-related surgery and during the hospital stay experienced delirium. Fifteen patients participated in the interviews. Of these, six had experienced episodes of nightly delirium (sundown syndrome) and nine experienced delirium during at least one day. The interviews were analysed by qualitative content analysis.

RESULTS

The entry of delirium was experienced as a sudden change of reality that, in some cases, could be connected to basic unfulfilled physiological needs. The delirium experiences were like dramatic scenes that gave rise to strong emotional feelings of fear, panic and anger. The experiences were also characterized by opposite pairs; they took place in the hospital but at the same time somewhere else; it was like dreaming but still being awake. The exit from the delirium was associated with disparate feelings.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to understand patients' thoughts and experiences during the delirious phase to be able to give professional care, both during the delirium phase and after the recovery.

Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients

OBJECTIVE

Acute brain dysfunction or delirium occurs in the majority of mechanically ventilated (MV) medical intensive care unit (ICU) patients and is associated with increased mortality. Unfortunately delirium often goes undiagnosed as health care providers fail to recognize in particular the hypoactive form that is characterized by depressed consciousness without the positive symptoms such as agitation. Recently, clinical tools have been developed that help to diagnose delirium and determine the subtypes. Their use, however, has not been reported in surgical and trauma patients. The objective of this study was to identify the prevalence of the motoric subtypes of delirium in surgical and trauma ICU patients.

METHODS

Adult surgical and trauma ICU patients requiring MV longer than 24 h were prospectively evaluated for arousal and delirium using well validated instruments. Sedation and delirium were assessed using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method in the ICU (CAM-ICU), respectively. Patients were monitored for delirium for a maximum of 10[Symbol: see text]days or until ICU discharge.

PATIENTS

A total of 100 ICU patients (46 surgical and 54 trauma) were enrolled in this study. Three patients were excluded from the final analysis because they stayed persistently comatose prior to their death.

MEASUREMENTS AND RESULTS

Prevalence of delirium was 70% for the entire study population with 73% surgical and 67% trauma ICU patients having delirium. Evaluation of the subtypes of delirium revealed that in surgical and trauma patients, hypoactive delirium (64% and 60%, respectively) was significantly more prevalent than the mixed (9% and 6%) and the pure hyperactive delirium (0% and 1%).

CONCLUSIONS

The prevalence of the hypoactive or "quiet" subtype of delirium in surgical and trauma ICU patients appears similar to that of previously published data in medical ICU patients. In the absence of active monitoring with a validated clinical instrument (CAM-ICU), however, this subtype of delirium goes undiagnosed and the prevalence of delirium in surgical and trauma ICU patients remains greatly underestimated.

Jordanian patients’ perception of stressors in critical care units: A questionnaire survey

BACKGROUND

Critical care units' CCUs environment has been regarded as a leading stressor because of the complex nature of patient's health problems that require an extensive use of very sophisticated technology. Multiple and complex care predominates in CCUs have been described by patients to be stressful and emotionally demanding.

RATIONALE

Number of CCUs in Jordan has been increasing and so does the advanced technology, which calls for adaptability in dealing with unit stressors as they affect patient recovery and rehabilitation.

OBJECTIVES

To identify the principal physical and psychological stressors as perceived by Jordanian patients in CCUs and to examine the effects of selected patients' characteristics on their perception of stressors.

METHODS

In this cross-sectional study, data was collected from 165 patients, 2-3 days after being discharged from CCUs in two Jordanian governmental hospitals. A structured interview guide including the Intensive Care Unit Environmental Stressor Scale was used.

RESULTS

Having tubes in nose or mouth, being in pain, not able to sleep and hearing the buzzers and alarms from the machinery, being thirsty, and not being in control of your-self were considered by patients as the main stressors. Psychological stressors were the least stressful items identified by patients. Marital status, educational level, age, and income were the most significant characteristics which affected patients' perception of stressors.

CONCLUSIONS

The findings suggest that single and older patients with low income and low education experience more difficulties than their counterparts. Nurses must utilize more effective communication techniques and interventions to relieve patients' pain, and provide an atmosphere in which rest is possible, with less light, noise, and the fewest possible interruptions. Although the results of this study indicate the need to provide the best possible physical care, it is equally important to give adequate attention to patients' and families' psychological aspects.

Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: results from a pilot, randomized trial

BACKGROUND

Observational studies suggest that open visiting policies are preferred by most patients and visitors in intensive care units (ICUs), but no randomized trial has compared the safety and health outcomes of unrestrictive (UVP) and restrictive (RVP) visiting policies. The aim of this pilot, randomized trial was to compare the complications associated with UVP (single visitor with frequency and duration chosen by patient) and RVP (single visitor for 30 minutes twice a day).

METHODS AND RESULTS

Two-month sequences of the 2 visiting policies were randomly alternated for 2 years in a 6-bed ICU, with 226 patients enrolled (RVP/UVP, n=115/111). Environmental microbial contamination, septic and cardiovascular complications, emotional profile, and stress hormones response were systematically assessed. Patients admitted during the randomly scheduled periods of UVP received more frequent (3.2+/-0.2 versus 2.0+/-0.0 visits per day, mean+/-SEM) and longer (2.6+/-0.2 versus 1.0+/-0.0 h/d) visits (P<0.001 for both comparisons). Despite significantly higher environmental microbial contamination during the UVP periods, septic complications were similar in the 2 periods. The risk of cardiocirculatory complications was 2-fold (odds ratio 2.0; 95% CI, 1.1 to 3.5; P=0.03) in the RVP periods, which were also associated with a nonsignificantly higher mortality rate (5.2% versus 1.8%; P=0.28). The UVP was associated with a greater reduction in anxiety score and a significantly lower increase in thyroid stimulating hormone from admission to discharge.

CONCLUSIONS

Despite greater environmental microbial contamination, liberalizing visiting hours in ICUs does not increase septic complications, whereas it might reduce cardiovascular complications, possibly through reduced anxiety and more favorable hormonal profile.

Recognition of delirium in ICU patients: a diagnostic study of the NEECHAM confusion scale in ICU patients

Background

A delirium, is a serious, high-frequency complication in intensive care unit (ICU) patients. The consequences of this complication range from high morbidity and mortality to greater need for nursing care. Despite these, delirium is often not recognized and there for not treated. In this study a nursing screening instrument, the NEECHAM confusion scale, was studied for early recognition of delirium ICU patients. This scale proved valid and reliable in several studies in the general hospital population.

Methods

In this study validity and reliability were tested in a prospective cohort of 105 patients. Gold standard for delirium was an independent DSM-IV diagnosis. User friendliness was tested by structured evaluation of nurses' experiences working with the scale.

Results

The NEECHAM confusion scale showed high internal consistency (Cronbach's alpha 0.88) and an interrater reliability of Cohen's Kappa 0.60. The concurrent validity with the DSM-IVcriteria showed a strong link (chi-square 67.52, p [less than or equal to] 0.001). Sensitivity was high, 97% and specificity was good 83%. ICU nurses completed the NEECHAM confusion rating in 3.69, ± 1.21 minutes average. In general the nurses were positive about the NEECHAM confusion scale. They were able to collect data during regular care, but experienced problems in rating the scale in intubated patients. The items in themselves were clear, the content validity, measured by the language used was rated good.

Conclusion

The psychometric characteristics of the NEECHAM confusion scale of this ICU study are generally consistent with validity research previously reported for the general hospital population. The psychometric characteristics and the ease of use of the NEECHAM confusion scale enables ICU nurses to early recognize delirium. Further study, especially in intubed patients is recommended.

‘Fishing with the dead’—Recall of memories from the ICU

The purpose of this study was to explore the memories of patients who had a short-term admission to the ICU, with a particular focus on dreams, nightmares and confusion. Descriptive data were collected from a target sample of 50 participants, by means of a questionnaire. Following this, eight patients who had completed and returned the questionnaire and had reported hallucinations, dreams or confusion participated in open-ended, semi-structured interviews. Analysis of the data generated by the questionnaire revealed that the most common memories of ICU were anxiety, pain, thirst and nausea. Nightmares, hallucinations and confusion were also common and were reported to be highly distressing. The transcribed interviews were subjected to a thematic analysis. The themes that emerged were, reality and unreality, blackness and colour, powerlessness and purpose, and death. Participants described horrifying paranoid delusions. It is proposed that constant reassurance and explaining every day ICU happenings may assist patients to understand what they are experiencing and loved ones may provide an important link with reality.

Psychological implications of admission to critical care

Admission to critical care can have far-reaching psychological effects because of the distinct environment. Critical care services are being re-shaped to address long-term sequelae, including post-traumatic stress disorder, anxiety and depression. The long-term consequences of critical illness not only cost the individual, but also have implications for society, such as diminished areas of health-related quality-of-life in sleep, reduced ability to return to work and enjoy recreational activities (Audit Commission, 1999; Hayes et al, 2000). The debate around the phenomenon of intensive care unit (ICU) syndrome is discussed with reference to current thinking. After critical care, patients may experience amnesia, continued hallucinations or flashbacks, anxiety, depression, and dreams and nightmares. Nursing care for patients while in the critical care environment can have a positive effect on psychological well-being. Facilitating communication, explaining care and rationalizing interventions, ensuring patients are oriented as to time and place, reassuring patients about transfer, providing patients,where possible, with information about critical care before admission and considering anxiolytic use, are all practices that have a beneficial effect on patient care. Follow-up services can help patients come to terms with their experiences of critical illness and provide the opportunity for them to access further intervention if desired. Working towards providing optimal psychological care will have a positive effect on patients' psychological recovery and may also help physical recuperation after critical care.

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.

Clinical updates: delirium

Delirium is a common cause of morbidity and mortality in hospitalized adults. Because delirium can significantly influence a patient's overall prognosis, identification of risk factors, early detection, and prompt, aggressive management of both delirium and its underlying cause are essential for positive outcomes. Education of practitioners and the use of standardized assessment tools can increase the recognition of the syndrome.

The impact of delirium on the survival of mechanically ventilated patients

OBJECTIVES

To revalidate a means of assessing delirium in intensive care unit patients and to investigate the independent effect of delirium on the mortality of mechanically ventilated patients.

DESIGN

A prospective cohort study.

SETTING

A 37-bed medical intensive care unit of a tertiary care hospital.

PATIENTS

Subjects were 102 of 131 consecutive mechanically ventilated patients.

MEASUREMENTS

All the enrolled patients were assessed for delirium using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Mortality rate were compared between patients with or without delirium, and the predictors of death were investigated.

RESULTS

The two CAM-ICU assessors' sensitivities in diagnosing delirium compared with reference standard were 91% and 95%, whereas their specificities were both 98%. They also demonstrated high interrater reliability with kappa statistics of 0.91. Delirium was present in 22 of 102 (22%) patients in the first 5 days. The delirious patients had higher intensive care unit mortality rate than nondelirious patients (63.6% vs. 32.5%, respectively), with a hazard ratio of 2.57 (95% confidence interval, 1.56-8.15). In multivariate analysis, delirium (odds ratio, 13.0; 95% confidence interval, 2.69-62.91), shock (odds ratio, 12.91; 95% confidence interval, 2.93-56.92), and illness severity (odds ratio, 9.61; 95% confidence interval, 2.24-41.18) were independent predictors of mortality.

CONCLUSIONS

This study confirms previous work showing that delirium is an independent predictor for increased mortality among mechanically ventilated patients.

Relatives' experiences of critical care

This exploratory study investigates relatives' overall experiences of the critical care environment and how staff perceived these experiences. Traditionally, research in Critical Care concentrated on patients' psychological well-being or relatives' immediate needs. There is little research that addresses the relative's overall experience of events. Critical Care Units are possibly the most daunting units in hospitals. Having a family member admitted to a Critical Care Unit could qualify as a traumatic-enough stressor to induce post-traumatic stress symptoms in relatives. A convenience sample of eight relatives and five staff participated in the study. The study used qualitative methods and drew on techniques of grounded theory. While staff perceived relatives' experiences accurately; issues arose, from both staff and relatives perspective, with regard to accurate dissemination of information. Further research into the communication processes used within Critical Care Units is required in addition to developing best practice in this area.

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.

British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units

Critical care nurses in the United Kingdom have become increasingly concerned about the use, potential abuse and risks associated with physical restraint of patients. Restraint in critical care is not only confined to physical restraint but can also encompass chemical and psychological methods. There are concerns regarding the legal and ethical issues relating to the (ab)use of physical restraint techniques in critical care. The aim of this article was to present the British Association of Critical Care Nurses (BACCN) position statement on the use of restraint in adult critical care units and to provide supporting evidence to assist clinical staff in managing this process.

The intensive care experience: development of the ICE questionnaire

BACKGROUND

Previous research has shown that patients' reported memories of intensive care are often of unpleasant events which are described as frightening and persecutory in nature. Currently, there is no standardized way of assessing perceptions of such an experience or relating it to long-term outcome.

AIMS

This paper describes the development of an intensive care experience questionnaire which aims to (a) identify the domains of such an experience, (b) assess and quantify that experience, and (c) explore its impact on short- and long-term emotional outcome.

METHODS

Data from two studies are reported. Participants were non-elective patients and > or =18 years of age with an ICU stay > or =24 hours. Study 1 (n = 34) generated and developed items. Study 2 (n = 109) allowed evaluation of the factor analytic structure and psychometrics of the questionnaire.

RESULTS

From a set of 31 items, exploratory factor analysis identified four components of the intensive care experience: 'awareness of surroundings' (nine items), 'frightening experiences' (six items), 'recall of experience' (five items), and 'satisfaction with care' (four items). Cronbach's alpha statistics were acceptable for each component (0.71-0.93). Correlational analysis with the subscales of the Hospital Anxiety and Depression Scale and Impact of Event Scale demonstrated concurrent and univariate predictive validity. The intensive care experience was associated with adverse emotional outcome in both the short- and long-term.

DISCUSSION

The intensive care experience questionnaire identified four dimensions of experience and performed satisfactorily in these developmental analyses. Further study of an independent intensive care unit data set is necessary to confirm these findings, including the four-component structure. Development of a standardized measure provides the opportunity to increase our understanding of the intensive care experience. The questionnaire may be useful to inform the development of effective interventions to improve subsequent outcomes for these patients.

Abolished circadian rhythm of melatonin secretion in sedated and artificially ventilated intensive care patients

BACKGROUND

Sleep disturbance is common in intensive care patients. Aside from its unpleasantness, there is a correlation with intensive care unit (ICU) syndrome/delirium. Reasons for sleep deprivation appear to be multifactorial, including the underlying illness, an acute superimposed disturbance, medications, and the ICU environment itself. There are reasons to believe that alterations of the 'biological clock' might contribute. Melatonin secretion is one reflection of this internal sleep/wake mechanism. Melatonin levels are normally high during the night and low during daytime, being suppressed by bright light.

METHODS

Melatonin levels in blood and urine were studied over 3 consecutive days in eight critically ill patients during deep sedation and mechanical ventilation. Sedation was assessed with the sedation-agitation (SAS) scale and bispectral index (BIS) monitor.

RESULTS

The circadian rhythm of melatonin release was abolished in all but one patient, who recovered much more quickly than the others. There was no correlation between melatonin levels and levels of sedation.

CONCLUSIONS

This study indicates that dyssynchronization of the melatonin secretion rhythm is common in critically ill and mechanically ventilated patients. It could be hypothesized that an impairment of the melatonin rhythm may play a role in the development of sleep disturbances and delirium in intensive care patients, and that melatonin supply could reduce the incidence of these phenomena.

Intensive care nurses' experiences of assessing and dealing with patients' psychological needs

Several authors have highlighted the short- and long-term psychological effects of an intensive care unit (ICU) stay. Few authors have discussed the nurses' perceptions of psychological care. In this research, 12 nurses, who currently work in ICU, were interviewed using a semi-structured technique. Six categories were developed about issues in psychological care. Implications for practice included the important role of the family, need for improved communication and improved staff awareness of issues.

Perception of stressors by patients and nurses of critical care units in Hong Kong

The frightening experience in critical care units, whether it be associated with the disease process or related to the critical care environment, has an important impact on clients' recovery and rehabilitation. A comparative descriptive study was conducted in the critical units of two major hospitals in Hong Kong to assess the perception of stressors by patients and nurses. A Chinese version of the Intensive Care Unit Environmental Stressor Scale (ICUESS) was used. Significant similarities and differences were noted between patients and nurses on their perceptions of stressors in the critical care environment. Critical care nurses, apart from maintaining their efforts to minimize the negative effects of the stressful critical care environment, needed to equally focus on the patients' psychological needs through measures in re-establishing patients' self-control and minimizing the emotional stress.

Nurses’ clinical experiences of the inverse bed position on a neurointensive care unit—a phenomenographic study

Our knowledge of unstable critically ill patients placed in an inverse bed position on the neurointensive care unit (NICU) is fairly limited. The purpose of this study was to ascertain the variation in nurses' conceptions of the impact of clinical experiences on the care and working environments among patients with the head towards the centre of the room on an NICU. An important research question was: how is the nursing care of patients facing inwards on an NICU perceived? Interviews were conducted and analysed with 15 nurses, using the method of phenomenography. From a nursing perspective, four descriptive categories were found, which partly distinguished the nursing psychosocial environment from the physical environment. These were safety and security of mobile computer tomography (CT) on the NICU, availability and overview, integrated holistic view in an open nursing psychosocial environment and adaptation of practical equipment. In conclusion, inverse bed position is important for more individualised neurointensive nursing care among unstable patients subjected to frequent CT scans on the unit. More stable patients should be turned back to the traditional bed position in order to promote their recovery process. This new knowledge is important for the development of quality assurance, with regard to, amongst other things, the patient's dignity.

Psychoneuroimmunology in critically ill patients

Psychoneuroimmunology is the study of the interactions among behavior, neural, and endocrine functions and the immune system. The purpose of this review is to briefly summarize the evidence concerning interactions among behavior, the neuroendocrine system, and the immune system, and to show how this evidence relates to critical care patients. It has been shown that the immune function of many patients in the intensive care unit is suppressed as a result of trauma, sepsis, or profound physiologic and psychological stress. Three of the most common stressors among patients in the intensive care unit are pain, sleep deprivation, and fear or anxiety. Findings have shown each of these stressors to be associated with decreased immune functioning. Nurses have an important responsibility to protect their patients from infection and promote their ability to heal. Several actions are suggested that can help the nurse achieve these goals. It is hoped that nurses would keep these interactions in mind while caring for their patients in the intensive care unit.

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.

Factors influencing the patient during weaning from mechanical ventilation: a national survey

Successful weaning depends on the application of skilled judgement and decision making to nursing and medical interventions. The intensive care nurse is in an unique position for adopting a holistic approach to weaning. Such an approach needs teamwork and consideration of all the factors that could influence the outcome of the weaning phase. The aim of this study was to conduct a survey, to establish the factors taken into consideration and documented during weaning at the intensive care units (ICUs) in Sweden. A questionnaire was developed and sent to all 92 ICUs. The results identified that nutrition, communication, analgesics and sedatives, psychological and metabolic factors, as well as weaning methods and measurable parameters were taken into consideration. Written instructions for weaning were used by only three ICUs and weaning protocols were not common. A holistic approach to the discontinuation of mechanical ventilation is a valuable means of improving the quality of care and merits further research.

Intensive care unit syndrome/delirium is associated with anemia, drug therapy and duration of ventilation treatment

BACKGROUND

We have performed a prospective qualitative investigation of the ICU syndrome/delirium; the main parts of which have recently been published. The aim of the present study was to explore the relationship between the ICU syndrome/delirium and age, gender, length of ventilator treatment, length of stay and severity of disease, as well as factors related to arterial oxygenation and the amount of drugs used for sedation/analgesia.

METHODS

Nineteen mechanically ventilated patients who had stayed in the ICU for more than 36 h were closely observed during their stay, and interviewed in depth twice after discharge. Demographic, administrative and medical data were collected as a part of the observation study.

RESULTS

Patients with severe delirium had significantly lower hemoglobin concentrations than those with moderate or no delirium (P=0.033). Patients suffering from severe delirium spent significantly longer time on the ventilator and at the ICU, and were treated with significantly higher daily doses of both fentanyl (P=0.011) and midazolam (P=0.011) in comparison with those reporting only moderate or no symptoms of delirium. There were no significant differences in the Therapeutic Intervention Scoring System scores, reflecting the degree of illness, between patients with and without delirium.

CONCLUSION

The development of the ICU syndrome/delirium seems to be associated with decreased hemoglobin concentrations and extended times on the ventilator. Prolonged ICU stays and treatment with higher doses of sedatives and opioids in patients with delirium appear to be secondary phenomena rather than causes.

Early recognition of delirium: review of the literature

This review focuses on delirium and early recognition of symptoms by nurses. Delirium is a transient organic mental syndrome characterized by disturbances in consciousness, thinking and memory. The incidence in older hospitalized patients is about 25%. The causes of delirium are multi-factorial; risk factors include high age, cognitive impairment and severity of illness. The consequences of delirium include high morbidity and mortality, lengthened hospital stay and nursing home placement. Delirium develops in a short period and symptoms fluctuate, therefore nurses are in a key position to recognize symptoms. Delirium is often overlooked or misdiagnosed due to lack of knowledge and awareness in nurses and doctors. To improve early recognition of delirium, emphasis should be given to terminology, vision and knowledge regarding health in ageing and delirium as a potential medical emergency, and to instruments for systematic screening of symptoms.