Effects of the ABCDE bundle on the prevention of post-intensive care syndrome: A retrospective study

Preventive effects of early mobilisation on delirium incidence in critically ill patients: systematic review and meta-analysis

OBJECTIVE

To evaluate whether early mobilisation can reduce the incidence of delirium in critically ill patients and to assess the methodological quality of published studies.

METHODS

Three electronic databases, PubMed, Embase and the Cochrane Library, were searched for relevant studies published up to 2 March 2024. Articles were screened independently by two reviewers, based on inclusion and exclusion criteria, and a meta-analysis was performed using RevMan 5.3 software with a random-effects model.

RESULTS

A total of 18 studies (intervention group: 1794 participants, control group: 2129 participants) were included in the systematic review, with 18 studies included in the meta-analysis. Early mobilisation was found to reduce the risk of delirium in critically ill populations, with a pooled odds ratio of 0.65 (95% confidence interval [CI] 0.49-0.86; P = 0.003; I2 = 59%). Additionally, two studies found that early mobilisation did not change the duration of delirium in critically ill populations, with a pooled mean difference of -1.53 (95% CI -3.48 to 0.41; P = 0.12; I2 = 37%). Subgroup analysis revealed that early mobilisation maintained its preventive effect on delirium in the before/after intervention studies, studies published before 2018 and studies with a moderate methodological rating.

CONCLUSION

As a nonpharmacological intervention, early mobilisation may help reduce the risk of delirium and shorten its duration in critically ill patients compared with standard treatment and may potentially become a novel strategy for delirium prevention in future intensive care unit settings.

Using Compressed Virtual Reality Exposure Therapy for an Adult Critical Illness Survivor: A Case Report

INTRODUCTION

Nearly one-quarter of adult critical illness survivors develop posttraumatic stress disorder symptoms triggered by sensory stimuli after intensive care unit discharge. Intensive care unit delirium is a risk factor for posttraumatic stress disorder. Compressed virtual reality exposure therapy (C-VRET) incorporates sensory stimuli to reduce posttraumatic stress disorder symptoms through habituation.

CLINICAL FINDINGS AND DIAGNOSIS

A critical illness survivor developed intensive care unit delirium and enrolled in a C-VRET trial to treat posttraumatic stress disorder. She reported self-isolation because of infection fears and posttraumatic stress disorder symptoms triggered by medical commercials and lawn equipment sounds. She repetitively checked her heart rate at night for fear of missing illness signs and waking up intubated.

INTERVENTIONS

The participant completed therapy. Screening tests were administered before, 2 weeks after, and 3 months after therapy to measure posttraumatic stress disorder symptoms (Clinician-Administered PTSD Scale for DSM-5; range, 0-60), depression (Center for Epidemiologic Studies Depression Scale; range, 0-60), physical activity (International Physical Activity Questionnaire), and resiliency (Connor-Davidson Resilience Scale; range, 0-100).

OUTCOMES

The participant's posttraumatic stress disorder symptom scores declined from 36 to 11 to 5; depression scores declined from 19 to 5 to 1; physical activity scores increased from 499 to 2013 to 4599; and resiliency scores increased from 70 to 76 to 83.

CONCLUSION

This report highlights the severity of posttraumatic stress disorder symptoms in critical illness survivors and the importance of strategies to limit delirium and posttraumatic stress disorder. Compressed virtual reality exposure therapy may reduce posttraumatic stress disorder symptoms in critical illness survivors.

Codesign of a Quality Improvement Tool for Adults With Prolonged Critical Illness: A Modified Delphi Consensus Study

OBJECTIVES

Increasing numbers of patients experience a prolonged stay in intensive care. Yet existing quality improvement (QI) tools used to improve safety and standardize care are not designed for their specific needs. This may result in missed opportunities for care and contribute to worse outcomes. Following an experience-based codesign process, our objective was to build consensus on the most important actionable processes of care for inclusion in a QI tool for adults with prolonged critical illness.

DESIGN

Items were identified from a previous systematic review and interviews with former patients, their care partners, and clinicians. Two rounds of an online modified Delphi survey were undertaken, and participants were asked to rate each item from 1 to 9 in terms of importance for effective care; where 1-3 was not important, 4-6 was important but not critical, and 7-9 was critically important for inclusion in the QI tool. A final consensus meeting was then moderated by an independent facilitator to further discuss and prioritize items.

SETTING

Carried out in the United Kingdom.

PATIENTS/SUBJECTS

Former patients who experienced a stay of over 7 days in intensive care, their family members and ICU staff.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We recruited 116 participants: 63 healthcare professionals (54%), 45 patients (39%), and eight relatives (7%), to Delphi round 1, and retained 91 (78%) in round 2. Of the 39 items initially identified, 32 were voted "critically important" for inclusion in the QI tool by more than 70% of Delphi participants. These were prioritized further in a consensus meeting with 15 ICU clinicians, four former patients and one family member, and the final QI tool contains 25 items, including promoting patient and family involvement in decisions, providing continuity of care, and structured ventilator weaning and rehabilitation.

CONCLUSIONS

Using experience-based codesign and rigorous consensus-building methods we identified important content for a QI tool for adults with prolonged critical illness. Work is underway to understand tool acceptability and optimum implementation strategies.

Characterization of Awareness and Depth of Blockade During Neuromuscular Blockade Infusions in Critically Ill Children

OBJECTIVE

The Society of Critical Care Medicine released the first guideline for the prevention and -management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients but offered conditional recommendations for sedation practices and monitoring during neuromuscular blockade. This study aimed to characterize sedation practices, patient awareness, and depth of blockade with neuromuscular blocking agent (NMBA) infusion administration in a single pediatric and cardiac intensive care unit.

METHODS

This retrospective chart review of critically ill pediatric patients queried orders for continuous infusion NMBA. Analgosedation agent(s), dose, and dose changes were assessed, along with depth of blockade monitoring via Train of Four (TOF) and awareness via Richmond Agitation and Sedation Scale (RASS).

RESULTS

Thirty-one patients were included, of which 27 (87%) had a documented sedation agent infusing at time of NMBA initiation and 17 patients (54%) were receiving analgesia. The most common agents used were rocuronium (n = 28), dexmedetomidine (n = 23), and morphine (n = 14). RASS scores were captured in all patients; however, 9 patients (29%) had recorded positive scores and 1 patient (3%) never achieved negative scores. TOF was only captured for 11 patients (35%), with majority of the scores being 0 or 4.

CONCLUSIONS

Majority of the study population did not receive recommended depth of blockade monitoring via TOF. Similarly, RASS scores were not consistent with deep sedation in half of the patients. The common use of dexmedetomidine as a single sedation agent calls into question the appropriateness of current sedation practices during NMBA continuous infusions.

Quality of life in ICU survivors and their relatives with post-intensive care syndrome: A systematic review

BACKGROUND

Post-intensive care syndrome (PICS) is characterized by all three adverse survivorship dimensions: physical function, cognitive function and mental health status.

AIM

This review aimed to describe the quality of life (QoL) of Intensive Care Unit (ICU) survivors with PICS after discharge and of their relatives with Family Post-intensive care syndrome (PICS-F) and to report anxiety, depression and Post-Traumatic Stress Disorders (PTSD) in studies investigating PICS.

STUDY DESIGN

A systematic review was carried out. We searched PubMed, Scopus, Web of Science and the Cumulative Index to Nursing and Allied Health Literature. This review was registered in the PROSPERO database (CRD42022382123).

RESULTS

We included 19 studies of PICS and PICS-F in this systematic review. Fourteen observational studies report the effects of PICS on depression, 12 studies on anxiety and nine on post-traumatic stress disorder and 10 on QoL. Mobility, personal care, usual activities and pain/discomfort in QoL were the domains most affected by PICS. A significant association was demonstrated between a high level of ICU survivors' anxiety and high levels of ICU relatives' burden. Strain-related symptoms and sleep disorders were problems encountered by ICU relatives with PICS-F.

CONCLUSION

PICS and PICS-F were widespread experiences among ICU survivors and their ICU relatives, respectively. The results of this review showed the adverse effects of PICS and PICS-F on QoL.

RELEVANCE TO CLINICAL PRACTICE

PICS and PICS-F strongly impact the rehabilitation process and are measured in terms of health costs, financial stress and potentially preventable readmission.

Post intensive care syndrome: A review of clinical symptoms, evaluation, intervention

Post intensive care syndrome (PICS) is a typical complication of critically ill patients during or after their stay in intensive care unit (ICU), characterized by a high incidence and impairment rate. It significantly impacts the quality of life of patients and their families, as well as consumes a substantial amount of medical resources. Therefore, early intervention and assessment of PICS is crucial. This paper aims to provide clinical professionals with a reference base by focusing on the clinical symptoms, diagnostic assessment, and preventative measures of PICS.

Clinical Impact of the Implementation Strategies Used to Apply the 2013 Pain, Agitation/Sedation, Delirium or 2018 Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption Guideline Recommendations: A Systematic Review and Meta-Analysis

OBJECTIVES

To summarize the effectiveness of implementation strategies for ICU execution of recommendations from the 2013 Pain, Agitation/Sedation, Delirium (PAD) or 2018 PAD, Immobility, Sleep Disruption (PADIS) guidelines.

DATA SOURCES

PubMed, CINAHL, Scopus, and Web of Science were searched from January 2012 to August 2023. The protocol was registered with PROSPERO (CRD42020175268).

STUDY SELECTION

Articles were included if: 1) design was randomized or cohort, 2) adult population evaluated, 3) employed recommendations from greater than or equal to two PAD/PADIS domains, and 4) evaluated greater than or equal to 1 of the following outcome(s): short-term mortality, delirium occurrence, mechanical ventilation (MV) duration, or ICU length of stay (LOS).

DATA EXTRACTION

Two authors independently reviewed articles for eligibility, number of PAD/PADIS domains, quality according to National Heart, Lung, and Blood Institute assessment tools, implementation strategy use (including Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment [ABCDEF] bundle) by Cochrane Effective Practice and Organization of Care (EPOC) category, and clinical outcomes. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation.

DATA SYNTHESIS

Among the 25 of 243 (10.3%) full-text articles included ( n = 23,215 patients), risk of bias was high in 13 (52%). Most studies were cohort ( n = 22, 88%). A median of 5 (interquartile range [IQR] 4-7) EPOC strategies were used to implement recommendations from two (IQR 2-3) PAD/PADIS domains. Cohort and randomized studies were pooled separately. In the cohort studies, use of EPOC strategies was not associated with a change in mortality (risk ratio [RR] 1.01; 95% CI, 0.9-1.12), or delirium (RR 0.92; 95% CI, 0.82-1.03), but was associated with a reduction in MV duration (weighted mean difference [WMD] -0.84 d; 95% CI, -1.25 to -0.43) and ICU LOS (WMD -0.77 d; 95% CI, -1.51 to 0.04). For randomized studies, EPOC strategy use was associated with reduced mortality and MV duration but not delirium or ICU LOS.

CONCLUSIONS

Using multiple implementation strategies to adopt PAD/PADIS guideline recommendations may reduce mortality, duration of MV, and ICU LOS. Further prospective, controlled studies are needed to identify the most effective strategies to implement PAD/PADIS recommendations.

Early Mobilization and Rehabilitation of Critically-Ill Patients

Post-intensive care unit (ICU) syndrome may occur after ICU treatment and includes ICU-acquired weakness (ICU-AW), cognitive decline, and mental problems. ICU-AW is muscle weakness in patients treated in the ICU and is affected by the period of mechanical ventilation. Diaphragmatic weakness may also occur because of respiratory muscle unloading using mechanical ventilators. ICU-AW is an independent predictor of mortality and is associated with longer duration of mechanical ventilation and hospital stay. Diaphragm weakness is also associated with poor outcomes. Therefore, pulmonary rehabilitation with early mobilization and respiratory muscle training is necessary in the ICU after appropriate patient screening and evaluation and can improve ICU-related muscle weakness and functional deterioration.

Clinical impact of rehabilitation and ICU diary on critically ill patients: A systematic review and meta‐analysis

Background

Various physical and mental sequelae reduce the quality of life (QOL) of intensive care unit (ICU) patients. Current guidelines recommend multi‐angular approaches to prevent these sequelae. Some studies have demonstrated the clinical effectiveness of rehabilitation or the ICU diary against these sequelae, whereas others have not.

Aim

The aims of the present study were to establish whether rehabilitation or the ICU diary was useful for reducing the severity of anxiety, depression, and post‐traumatic stress disorder (PTSD) in ICU patients. We also investigated whether these interventions improved the QOL of these patients.

Study design

We conducted a systematic review and meta‐analysis of relevant randomized controlled trials published between January 1, 1985, and October 19, 2022, with the following search engines: PubMed, CHINAHL, all Ovid journals, and CENTRAL. The hospital anxiety and depression scale (HADS), the short‐form health survey (SF‐36), the EuroQol 5‐dimensions, 5‐levels (EQ‐5D‐5L), and the Impact of Event Scale‐Revised (IES‐R) were used as outcome measures. The quality of evidence across all studies was independently assessed using Review Manager software (v.5.4).

Results

We included 12 rehabilitation studies and five ICU diary studies. Rehabilitation had no significant effects on HADS‐anxiety, HADS‐depression, or EQ‐5D‐5L, but significantly improved the physical component summary (PCS) [MD = 3.31, 95%CI (1.33 to 5.28), p = .001] and mental component summary (MCS) [MD = 4.31, 95%CI: (1.48 to 7.14), p = .003] of the SF‐36. The ICU diary significantly ameliorated HADS‐anxiety [MD = 0.96, 95%CI: (0.21 to 1.71), p = .01], but did not affect HADS‐depression, the IES‐R, or the PCS or MCS of the SF‐36.

Conclusions

The present study showed that rehabilitation initiated after discharge from the ICU effectively improved SF‐36 scores. The ICU diary ameliorated HADS‐anxiety. Neither rehabilitation nor the ICU diary attenuated HADS‐depression or IES‐R in this setting. Rehabilitation and the ICU diary partially improved the long‐term prognosis of ICU patients.

Relevance to clinical practice

The present study provides evidence for the beneficial effects of rehabilitation and the ICU diary for ICU patients. Rehabilitation alone does not ameliorate anxiety, depression, or PTSD symptoms, but may improve QOL. The ICU diary only appeared to ameliorate anxiety.

Pediatric Critical Care Outcomes: State of the Science

Children who survive the pediatric intensive care unit (PICU) are at risk of developing post-intensive care syndrome in pediatrics (PICS-p). PICS-p, defined as new physical, cognitive, emotional, and/or social health dysfunction following critical illness, can affect the child and family. Historically, synthesizing PICU outcomes research has been challenging due to inconsistency in study design and in outcomes measurement. PICS-p risk may be mitigated by implementing intensive care unit best practices that limit iatrogenic injury and by supporting the resiliency of critically ill children and their families.

Perioperative Optimization of the Cardiac Surgical Patient

Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.

The effect of the ABCDE/ABCDEF bundle on delirium, functional outcomes, and quality of life in critically ill patients: A systematic review and meta-analysis

BACKGROUND

The effect of the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and spontaneous breathing trials; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment) on patient outcomes such as delirium is potentially optimised when the bundle is implemented in its entirety.

OBJECTIVE

To systematically synthesise the evidence on the effectiveness of the ABCDEF bundle delivered in its entirety on delirium, function, and quality of life in adult intensive care unit patients.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

Electronic databases including MEDLINE, CINAHL, PsycINFO, Web of Science, Cochrane Library, Joanna Briggs Institute's Evidence Based Practice, Australian New Zealand Clinical Trials Registry, and Embase were searched from 2000 until December 2021.

REVIEW METHODS

Inclusion criteria included (1) adult intensive care unit patients (2) studies that described the ABCDE or ABCDEF bundle in its entirety (3) studies that evaluated delirium, functional outcomes, or quality of life. Studies were excluded if they investigated long-term intensive care unit rehabilitation patients. Two reviewers independently screened records and full text, extracted data, and undertook quality appraisals with discrepancies discussed until consensus was reached. Random effects meta-analyses were conducted for delirium but was not possible for other outcomes. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess the certainty of the synthesised findings of the body of evidence. The study protocol was registered on PROSPERO (CRD 42019126407).

RESULTS

A total of 18 studies (29,576 patients) were included in the descriptive synthesis. Meta-analysis of six studies (2000 patients) identified decreased delirium incidence following implementation of the ABCDEF bundle when compared with standard practice, (risk ratio = 0.57; CI, 0.36-0.90 p = 0.02) although heterogeneity was high (I² = 92%). When compared with standard practice, a meta-analysis of five studies (3418 patients) showed the ABCDEF bundle statistically significantly reduced the duration of intensive care unit delirium (mean difference (days) - 1.37, 95% CI -2.61 to -0.13 p = 0.03; I² 96%). Valid functional assessments were included in two studies, and quality of life assessment in one.

CONCLUSIONS

Although the evidence on the effect of the ABCDEF bundle delivered in its entirety is limited, positive patient delirium outcomes have been shown in this meta-analysis. As this meta-analysis was based on only 4736 patients in eight studies, further evidence is required to support its use in the adult intensive care unit.

REGISTRATION DETAILS

PROSPERO (CRD 42019126407).

A Step Forward for Intensive Care Unit Patients: Early Mobility Interventions and Associated Outcome Measures

Background

Critical illness survivors have impairments across physical, psychological, and cognitive health domains known as post–intensive care syndrome. Although physical activity can improve outcomes across all health domains, most intensive care unit early mobility studies focus solely on physical outcomes.

Objective

To explore the role of early mobility for adult patients in the intensive care unit by analyzing early mobility intervention studies with physical, psychological, or cognitive outcome measures.

Methods

This integrative review used Whittemore and Knafl’s methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, Embase, PubMed, PsycINFO, and Scopus databases were searched for primary research articles published from 2005 through 2021 on adult intensive care unit early mobility interventions evaluated by physical, cognitive, or psychological outcome measures during or after intervention delivery. Interventions comprising only passive mobility were excluded.

Results

Of 1009 articles screened, 20 were included. Variations in outcome measures, measurement timing, instruments, and control groups made synthesis difficult. No study evaluated an intervention using outcome measures from all 3 health domains. Five studies measured physical and cognitive outcomes; 6 studies measured physical and psychological outcomes.

Conclusion

Early mobility is primarily addressed objectively and unidimensionally, limiting understanding of the implications of early mobility for patients. Post–intensive care syndrome prevention begins in the intensive care unit; early mobility is a promising intervention for targeting multiple risk factors. Studies that measure outcomes in all health domains during or after early mobility are needed to better evaluate the comprehensive effects of early mobility.

Informing the standardising of care for prolonged stay patients in the intensive care unit: A scoping review of quality improvement tools

OBJECTIVES

To inform design of quality improvement tools specific to patients with prolonged intensive care unit stay, we determined characteristics (format/content), development, implementation and outcomes of published multi-component quality improvement tools used in the intenisve care unit irrespective of length of stay.

RESEARCH METHODOLOGY

Scoping review searching electronic databases, trial registries and grey literature (January 2000 to January 2022).

RESULTS

We screened 58,378 citations, identifying 96 studies. All tools were designed for use commencing at intensive care unit admission except three tools implemented at 3, 5 or 14 days. We identified 32 studies of locally developed checklists, 28 goal setting/structured communication templates, 23 care bundles and 9 studies of mixed format tools. Most (43 %) tools were designed for use during rounds, fewer tools were designed for use throughout the ICU day (27 %) or stay (9 %). Most studies (55 %) reported process objectives i.e., improving communication, care standardisation, or rounding efficiency. Most common clinical processes quality improvement tools were used to standardise were sedation (62, 65 %), ventilation and weaning (55, 57 %) and analgesia management (58, 60 %). 44 studies reported the effect of the tool on patient outcomes. Of these, only two identified a negative effect; increased length of stay and increased days with pain and delirium.

CONCLUSION

Although we identified numerous quality improvement tools for use in the intensive care unit, few were designed to specifically address actionable processes of care relevant to the unique needs of prolonged stay patients. Tools that address these needs are urgently required.

SYSTEMATIC REVIEW REGISTRATION

The review protocol is registered on the Open Science Framework, https://osf.io/, DOI 10.17605/OSF.IO/Z8MRE.

Creation of an International Interprofessional Simulation-enhanced Mechanical Ventilation Course

Background

Evidence shows poor adherence to strategies for reducing morbidity and mortality in intensive care unit (ICU) patients receiving mechanical ventilation globally. Best practice management relies on training all members of the interprofessional ICU team, each with complementary roles in patient management.

Objectives

To develop and evaluate a novel two-phase, train-the-trainer, interprofessional and multicultural “Best Practice Management of the Ventilated ICU Patient” multimodality, simulation-enhanced curriculum for Thai education leaders in critical care.

Methods

In phase 1 (Oregon Health and Science University cohort), two groups of nine ICU nurses and one critical care physician representing experts in critical care and education from a large hospital system in Thailand participated in a weeklong, immersive course consisting of didactic, simulation, and in situ immersive sessions focused on best practice management of mechanically ventilated ICU patients, as well as training in our educational techniques. Outcomes were assessed with pre- and postcourse knowledge assessments and overall course evaluation. In phase 2 (Thai cohort), participants from phase 1 returned to Thailand and implemented a lower fidelity curriculum in two hospitals, using the same pre- and posttest knowledge assessment in 41 participants, before the onset of the coronavirus disease (COVID-19) 6 pandemic.

Results

In the Oregon Health and Science University cohort, the mean pretest knowledge score was 58.4 ± 13.2%, with a mean improvement to 82.5 ± 11.6% after completion of the course (P , 0.05). The greatest improvements were seen in respiratory physiology and advanced/disease-specific concepts, which demonstrated absolute improvements of 30.4% and 30.6%, respectively (P < 0.05). Participants had a high degree of satisfaction, with 90% rating the course as “excellent” and .90% reporting that the course “greatly improved” their understanding of best practices and comfort in managing mechanical ventilation. The Thai cohort had a mean baseline score of 45.4 ± 15.0% and a mean improvement to 70.3 ± 19.1% after training (P < 0.05). This cohort also saw the greatest improvement in respiratory physiology and advanced/disease-specific concepts, with 26.2% and 26.3% absolute improvements, respectively (P < 0.05).

Conclusion

A novel, two-phase, interprofessional, multicultural, simulation-enhanced train-the-trainer curriculum was feasible and effective in improving education in best practice management of mechanically ventilated patients and may be a useful model for improving the care of ICU patients across the world.

The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study

BACKGROUND

The ABCDE bundle is a set of evidence-based practices to systematically reduce the risks of sedation, delirium, and immobility in intensive care patients. Implementing the bundle improves clinical outcome.

AIMS AND OBJECTIVES

To investigate the association between patient outcomes and compliance with bundle components ABC (analgosedation algorithms), D (delirium protocol), and E (early mobilization protocol).

DESIGN

A Spanish multicentre cohort study of adult patients receiving invasive mechanical ventilation (IMV) for ≥48 h until extubation.

METHODS

The primary outcome was pain level, cooperation to permit Medical Research Council Scale administration, patient days of delirium, and mobility. The secondary outcome was cumulative drug dosing by IMV days. Tertiary outcomes (ICU days, IMV days, bed rest days, ICU mortality, ICUAW) and independent variables (analgosedation, delirium, early mobilization protocols) were also studied.

RESULTS

Data were collected from 605 patients in 80 ICUs and 5214 patient days with IMV. Two-thirds of the ICUs studied applied no protocols. Pain was not assessed on 83.6% of patient days. Patient cooperation made scale administration feasible on 20.7% of days. Delirium and immobility were found on 4.2% and 69.9% of days, respectively. Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03, respectively). Analgosedation protocols were associated with more opioid dosing (P = 0.02), and delirium and early mobilization protocols with more propofol (P = 0.001), dexmedetomidine (P = 0.001), and lower benzodiazepine dosing (P = 0.008).

CONCLUSIONS

The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation.

RELEVANCE TO CLINICAL PRACTICE

Applying some but not all the bundle components, there is increased analgesia and light sedation drug use, decreased benzodiazepines, and increased patient cooperation and mobility, resulting in a shorter ICU stay and fewer days of IMV.

Mixed-method research protocol: Development and evaluation of a nursing intervention in patients discharged from the intensive care unit

AIM

(a) To understand patients' lived experience at intensive care unit (ICU) discharge and (b) to evaluate the impact of a nursing empowerment intervention (NEI) on patients' anxiety and depression levels at ICU discharge.

DESIGN

A mixed-methods approach will be applied.

METHODS

In the qualitative phase, the hermeneutic phenomenological method will be used. Participants will be patients from three university hospitals who will be selected by purposive sampling. Data will be gathered through in-depth interviews and analysed using content analysis. The qualitative data obtained will be employed to develop the nursing intervention. Subsequently, a multicenter, parallel-group, experimental pre-test/post-test design with a control group will be used to measure the effectiveness of the nursing empowerment intervention in the quantitative phase by means of the Hospital Anxiety and Depression Scale (HADS). Simple random probabilistic sampling will include 172 patients in this phase.

Distorted Memories and Related Factors in ICU Patients

This study aimed to examine the relationship between memory status of and factors related to patients in the intensive care unit (ICU) using a cross-sectional study design. Participants were adult patients who were admitted to the general ICUs for more than 48 hours. One week after ICU discharge, a survey on memory distortion was conducted. Overall, 133 patients were included, of whom 51.1% reported distorted memories. Among them, 15.0% had memory loss; 48.1% had unrealistic experiences; 27.8% recalled confusion, panic, anxiety, and discomfort during their ICU stay; and 9% had traumatic experiences. Multiple logistic regression analyses revealed that memory loss was associated with an operation, and a significant association was observed between traumatic memory and pain. Opioid use may have a protective effect against memory loss. These results suggest the importance of relieving pain and preserving true memories during ICU treatment.

The effect of postintensive care syndrome on the quality of life of intensive care unit survivors: A secondary analysis

BACKGROUND

Despite increasing interest in postintensive care syndrome and the quality of life of intensive care unit survivors, the empirical literature on the relationship between these two variables is limited.

OBJECTIVES

This study aimed to examine whether postintensive care syndrome predicts the quality of life of intensive care unit survivors.

METHODS

We analysed secondary data, which were collected as part of a larger cross-sectional study. The participants were recruited from six health institutions in Korea. The data of 496 survivors who had been admitted to an intensive care unit for at least 48 h during the past year were analysed. They responded to measures of postintensive care syndrome and quality of life.

RESULTS

The participants' mean physical and mental component summary scores (quality of life) were 40.08 ± 8.99 and 40.24 ± 11.19, respectively. Physical impairment (β = -0.48, p < 0.001), unemployment (β = -0.19, p < 0.001), low income (β = -0.11, p = 0.004), older age (β = -0.08, p = 0.039), and cognitive impairment (β = -0.11, p = 0.045) predicted lower physical component summary scores. Mental (β = -0.49, p < 0.001) and cognitive impairment (β = -0.14, p = 0.005) and low income (β = -0.09, p = 0.014) predicted mental component summary scores.

CONCLUSIONS

The participants reported poor physical and mental health-related quality of life. Postintensive care syndrome, unemployment, low income, and older age were the main predictors of poor quality of life. In addition, postintensive care syndrome was a stronger risk factor for poor quality of life than demographic characteristics and intensive care unit treatment factors.