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Glæemose AO, Hanifa ALB, Haslund-Thomsen H. Peer support in intensive care unit follow-up: A qualitative evaluation. Nurs Crit Care 2024. [PMID: 38740516 DOI: 10.1111/nicc.13089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/19/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Patients formerly admitted to an intensive care unit and their relatives seek information about life after critical illness to understand their symptoms and what to expect as survivors, and they express a desire to talk to others with similar experiences. Various operational models of post-intensive care peer support exist, and studies have reported potential beneficial mechanisms in patients involved in peer support programs. However, most models have not been formally evaluated. AIM To evaluate the content and setting of structured group meetings and explore participants' experiences of meeting peers. STUDY DESIGN A qualitative evaluation combining focused ethnographic observations and semi-structured interviews with 22 participants attending three intensive care unit café meetings in a university hospital. A thematic analysis was conducted using all data collected. FINDINGS Three main themes emerged; 'Accommodating the diversity of patients and relatives', 'A range of possibilities for identification' and 'A newfound community'. Findings indicate that the content, setting and timing of the café meetings were of minor concern for the participants. Patients and relatives should attend together because the consequences of surviving a critical illness affect both. Larger groups of participants appeared to increase the likelihood of encountering broad variances in participants' experiences from the critical illness trajectory. The findings indicate that before attending a meeting, the participants did not find previous experiences sufficient in managing their new life situations and they felt alone in their experiences. CONCLUSION Peer support invited participants into a secure community and eased their sense of being alone in their struggles. Meeting peers seemed to be more important than following a specific model of peer support. RELEVANCE TO CLINICAL PRACTICE When setting up peer support for former intensive care patients, the most important aspect is to create a secure space for patients and their relatives to meet.
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Affiliation(s)
- Anne Okkels Glæemose
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Ann Louise Bødker Hanifa
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Helle Haslund-Thomsen
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Gistrup, Denmark
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2
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Haines KJ, Hibbert E, Skinner EH, Leggett N, Holdsworth C, Ali Abdelhamid Y, Bates S, Bicknell E, Booth S, Carmody J, Deane AM, Emery K, Farley KJ, French C, Krol L, MacLeod-Smith B, Maher L, Paykel M, Iwashyna TJ. In-person peer support for critical care survivors: The ICU REcovery Solutions cO-Led through surVivor Engagement (ICURESOLVE) pilot randomised controlled trial. Aust Crit Care 2024:S1036-7314(24)00022-5. [PMID: 38360469 DOI: 10.1016/j.aucc.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Peer support is a promising intervention to mitigate post-ICU disability, however there is a paucity of rigorously designed studies. OBJECTIVES The objective of this study was to establish feasibility of an in-person, co-designed, peer-support model. METHODS Prospective, randomised, adaptive, single-centre pilot trial with blinded outcome assessment, conducted at a university-affiliated hospital in Melbourne, Australia. Intensive care unit survivors (and their nominated caregiver, where survivor and caregiver are referred to as a dyad), >18 years of age, able to speak and understand English and participate in phone surveys, were eligible. Participants were randomised to the peer-support model (six sessions, fortnightly) or usual care (no follow-up or targeted information). Two sequential models were piloted: 1. Early (2-3 weeks post hospital discharge) 2. Later (4-6 weeks post hospital discharge). Primary outcome was feasibility of implementation measured by recruitment, intervention attendance, and outcome completion. Secondary outcomes included post-traumatic stress and social support. RESULTS Of the 231 eligible patients, 80 participants were recruited. In the early model we recruited 38 participants (28 patients, 10 carers; 18 singles, 10 dyads), with an average (standard deviation) age of 60 (18) years; 55 % were female. Twenty-two participants (58 %) were randomised to intervention. Participants in the early intervention model attended a median (interquartile range) of 0 (0-1) sessions (total 24 sessions), with 53% (n = 20) completing the main secondary outcome of interest (Impact of Event Scale) at the baseline and 37 % (n = 14) at the follow-up. For the later model we recruited 42 participants (32 patients, 10 carers; 22 singles, 10 dyads), with an average (standard deviation) age of 60.4 (15.4) years; 50 % were female. Twenty-one participants (50 %) were randomised to intervention. The later intervention model attended a median (interquartile range) of 1 (0-5) sessions (total: 44 sessions), with the main secondary outcome impact of events scale (IES-R) completed by 41 (98 %) participants at baseline and 29 (69 %) at follow-up. CONCLUSIONS In this pilot trial, a peer-support model that required in-person attendance delivered in a later posthospital phase of recovery appeared more feasible than an early model. Further research should investigate alternative modes of intervention delivery to improve feasibility (ACTRN12621000737831).
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Affiliation(s)
- Kimberley J Haines
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia.
| | - Elizabeth Hibbert
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | | | - Nina Leggett
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Clare Holdsworth
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Department of Intensive Care, Melbourne Health, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Samantha Bates
- Department of Intensive Care, Western Health, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Erin Bicknell
- Department of Physiotherapy, Melbourne Health, Melbourne, Australia
| | - Sarah Booth
- Department of Social Work, Western Health, Melbourne, Australia
| | - Jacki Carmody
- Department of Psychology, Western Health, Melbourne, Australia
| | - Adam M Deane
- Department of Intensive Care, Melbourne Health, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Kate Emery
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | - K J Farley
- Department of Intensive Care, Western Health, Melbourne, Australia
| | - Craig French
- Department of Intensive Care, Western Health, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Lauren Krol
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | | | - Lynne Maher
- Ko Awatea, Health System Innovation and Improvement, Counties Manukau Health, Auckland, New Zealand
| | - Melanie Paykel
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | - Theodore J Iwashyna
- Pulmonary and Critical Care Medicine, School of Medicine, John Hopkins University, Baltimore, MD, United States
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3
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Leggett AN, Robinson-Lane SG, Oxford G, Leonard N, Carmichael AG, Baker E, Paratore J, Blok AC, Prescott HC, Iwashyna TJ, Gonzalez R. Barriers to and Facilitators of Family Caregiving of Patients With COVID-19 Early in the Pandemic. Am J Crit Care 2023; 32:431-439. [PMID: 37907378 DOI: 10.4037/ajcc2023364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
BACKGROUND In 2020, many family members were thrust into the role of caregiving for a relative with COVID-19 with little preparation, training, or understanding of the disease and its symptoms. OBJECTIVES To explore the barriers to and facilitators of caregiving experienced by family caregivers of patients with COVID-19 who had been in intensive care in the pandemic's earliest months. METHODS In-depth qualitative interviews were conducted by web conference with 16 adults recovering at home after intubation for COVID-19 in an intensive care unit at a major academic medical center and their primary caregivers from March to August 2020 (N = 32). Thematic qualitative analysis was done using Watkins' rigorous and accelerated data reduction technique with MAXQDA software. RESULTS Seven themes emerged regarding factors that facilitated or posed barriers to care: other health conditions that increased complexity of care, interactions and experiences in the health care system, COVID-19's proliferation into other areas of life, the psychological well-being of the patient-caregiver dyad, experience of support from the dyad's network, the role of caregiving in the dyad, and contextual circumstances of the dyad. The themes often included both barriers and facilitators, depending on the experience of the dyad (eg, feeling encouraged vs fatigued by their support network). CONCLUSIONS Understanding how patients with COVID-19 and their caregivers experience illness management across the recovery journey can help clarify the COVID-19 care-giving process and identify intervention targets to improve overall health and well-being of the care dyad.
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Affiliation(s)
- Amanda N Leggett
- Amanda N. Leggett is an assistant professor in the Institute of Gerontology at Wayne State University, Detroit, Michigan, and an adjunct assistant professor, Department of Psychiatry, School of Medicine, University of Michigan Ann Arbor
| | - Sheria G Robinson-Lane
- Sheria G. Robinson-Lane is an assistant professor, Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan Ann Arbor
| | - Grace Oxford
- Grace Oxford is a research assistant, Biosocial Methods Collaborative, University of Michigan Ann Arbor
| | - Natalie Leonard
- Natalie Leonard is a research technician, Research Center for Group Dynamics, Institute for Social Research, University of Michigan Ann Arbor
| | - Alicia G Carmichael
- Alicia G. Carmichael is a research process manager, Research Center for Group Dynamics, Institute for Social Research, University of Michigan Ann Arbor
| | - Elaina Baker
- Elaina Baker is a research assistant, Department of Psychiatry, School of Medicine, University of Michigan Ann Arbor
| | - Janeann Paratore
- Janeann Paratore is a research assistant, Biosocial Methods Collaborative, University of Michigan Ann Arbor
| | - Amanda C Blok
- Amanda C. Blok is a research assistant professor, Department of Systems, Populations and Leadership, School of Nursing, University of Michigan and a research health scientist, VA Center for Clinical Management Research, Ann Arbor VA Healthcare System, Ann Arbor, Michigan
| | - Hallie C Prescott
- Hallie C. Prescott is an associate professor, Pulmonary and Critical Care, Department of Internal Medicine, School of Medicine, University of Michigan and a research investigator, VA Center for Clinical Management Research, Ann Arbor VA Healthcare System
| | - Theodore J Iwashyna
- Theodore J. Iwashyna is the Bloomberg Distinguished Professor of Social Science and Justice in Medicine and professor of medicine, Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Richard Gonzalez
- Richard Gonzalez is the Amos N. Tversky Professor, Psychology and Statistics and director, Research Center for Group Dynamics, University of Michigan
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Clarke R, Chow H, Kerrison K. An Intensive Care Unit peer support group: Participants' views on format, content and the impact on recovery journeys. J Intensive Care Soc 2023; 24:258-264. [PMID: 37744077 PMCID: PMC10515330 DOI: 10.1177/17511437221108905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background Peer support groups reduce psychological morbidity and increase social support for Intensive Care Unit (ICU) survivors. Group formats differ and research, although emerging, is limited. This study explores a continuously running ICU Expert by Experience group, which has a dual role of support and service-user consultative, from attendees' perspectives. Methods A thematic analysis was conducted on interviews with current and past members of an ICU Expert by Experience group. 11 participants took part in online and telephone interviews. Three provided written responses. Final themes were created following a process of data validation with participants. Results Four main themes emerged: (1) Support in the difficult recovery journey (2) Relationships and shared experiences (3) Value of professional facilitation (4) Practical considerations. Conclusion Patients highlighted the help gained from the group as an integral part of their recovery journey. Results also identified practical implications for those considering setting up similar support groups.
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Affiliation(s)
- Rachel Clarke
- Department of Critical Care, Derriford Hospital, Plymouth, UK
| | - Homen Chow
- Department of Clinical Psychology, Plymouth University, Plymouth, UK
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5
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Clarissa C. Recovery after intensive care—A critical commentary on
Dear ICU Survivor
by Mark Hudson. Nurs Crit Care 2023. [PMID: 37379005 DOI: 10.1111/nicc.12903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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6
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McPeake J, Kentish-Barnes N, Banse E, Anderson L, Cuzco C, Azoulay E, Quasim T, Castro P, Puxty K. Clinician perceptions of the impact of ICU family visiting restrictions during the COVID-19 pandemic: an international investigation. Crit Care 2023; 27:33. [PMID: 36681838 PMCID: PMC9862209 DOI: 10.1186/s13054-023-04318-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/11/2023] [Indexed: 01/22/2023] Open
Abstract
PURPOSE To guarantee the safety of the public, clinicians and patients during the COVID-19 pandemic, hospital visits were severely restricted internationally. There are limited data on the precise impact of these visiting restrictions on Intensive Care Unit clinicians. Our objectives therefore were to explore the impact of family visitation restrictions on clinicians and care delivery and describe innovation alongside areas for potential improvement. METHODS A qualitative approach using focus groups was employed. We recruited members of the multi-disciplinary team from Spain, France and the UK. Framework analysis was used to synthesize and interpret data. RESULTS In total, 28 staff from multiple international sites contributed to data across six focus groups: 12 from the UK, 9 from France and 7 from Spain. In relation to the key aims, we derived four themes: the emergence of new technologies, relationships and rapport establishment, communication challenges and end-of-life care provision. Across each theme, the overarching concepts of clinician emotional exhaustion and emotional distress emerged alongside the negative impact on job satisfaction. CONCLUSION The impact of COVID-19 family visitation restrictions is far reaching. Future research should examine the wider impact of family presence in the ICU.
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Affiliation(s)
- Joanne McPeake
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Nancy Kentish-Barnes
- AP-HP Nord, Saint Louis Hospital, Medical Intensive Care, Famiréa Research Group, Paris, France
| | - Emilie Banse
- Psychological Sciences Research Institute, Université Catholique de Louvain, Louvain-La-Neuve, Belgium
| | - Lynne Anderson
- Department of Anaesthetics, Golden Jubilee National Hospital, Glasgow, UK
| | - Cecilia Cuzco
- Medical Lntensive Care Unit, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Department of Fundamental Care and Medical-Surgical Nursing, Nursing School of Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Elie Azoulay
- AP-HP Nord, Saint Louis Hospital, Medical Intensive Care, Famiréa Research Group, Paris, France
| | - Tara Quasim
- Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Pedro Castro
- Medical Lntensive Care Unit, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Kathryn Puxty
- Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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Abstract
OBJECTIVES To engage critical care end-users (survivors and caregivers) to describe their emotions and experiences across their recovery trajectory, and elicit their ideas and solutions for health service improvements to improve the ICU recovery experience. DESIGN End-user engagement as part of a qualitative design using the Framework Analysis method. SETTING The Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS Patients and caregivers following critical illness and identified through the collaboratives. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty-six interviews were conducted. The following themes were identified: 1) Emotions and experiences of patients-"Loss of former self; Experiences of disability and adaptation"; 2) Emotions and experiences of caregivers-"Emotional impacts, adopting new roles, and caregiver burden; Influence of gender roles; Adaptation, adjustment, recalibration"; and 3) Patient and caregiver-generated solutions to improve recovery across the arc of care-"Family-targeted education; Expectation management; Rehabilitation for patients and caregivers; Peer support groups; Reconnecting with ICU post-discharge; Access to community-based supports post-discharge; Psychological support; Education of issues of ICU survivorship for health professionals; Support across recovery trajectory." Themes were mapped to a previously published recovery framework (Timing It Right) that captures patient and caregiver experiences and their support needs across the phases of care from the event/diagnosis to adaptation post-discharge home. CONCLUSIONS Patients and caregivers reported a range of emotions and experiences across the recovery trajectory from ICU to home. Through end-user engagement strategies many potential solutions were identified that could be implemented by health services and tested to support the delivery of higher-quality care for ICU survivors and their caregivers that extend from tertiary to primary care settings.
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8
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Affiliation(s)
- Aluko A Hope
- Aluko A. Hope is coeditor in chief of the American Journal of Critical Care. He is an associate professor and physician scientist at Oregon Health and Science University in Portland, Oregon
| | - Cindy L Munro
- Cindy L. Munro is coeditor in chief of the American Journal of Critical Care. She is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
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9
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Hope AA, McPeake J. Healthcare delivery and recovery after critical illness. Curr Opin Crit Care 2022; 28:566-571. [PMID: 35975964 DOI: 10.1097/mcc.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To summarize improvements and innovations in healthcare delivery which could be implemented to improve the recovery experience after critical illness for adult survivors and their families. RECENT FINDINGS For survivors of critical illness, the transitions in care during their recovery journey are points of heightened vulnerability associated with adverse events. Survivors of critical illness often have errors in the management of their medications during the recovery period. A multicomponent intervention delivered for 30 days that focused on four key principles of improved recovery care after sepsis care was associated with a durable effect on 12-month rehospitalization and mortality compared with usual care. A recent multicentre study which piloted integrating health and social care for critical care survivors demonstrated improvements in health-related quality of life and self-efficacy at 12 months. Multiple qualitative studies provide insights into how peer support programmes could potentially benefit survivors of critical illness by providing them mechanism to share their experiences, to give back to other patients, and to set more realistic expectations for recovery. SUMMARY Future research could focus on exploring safety outcomes as primary endpoints and finding ways to develop and test implementation strategies to improve the recovery after critical illness.
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Affiliation(s)
- Aluko A Hope
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA
| | - Joanne McPeake
- The Institute of Healthcare Improvement Studies, University of Cambridge, Cambridge
- The Improvement Hub, Healthcare Improvement Scotland, Glasgow, UK
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Gorman EA, O'Kane CM, McAuley DF. Acute respiratory distress syndrome in adults: diagnosis, outcomes, long-term sequelae, and management. Lancet 2022; 400:1157-1170. [PMID: 36070788 DOI: 10.1016/s0140-6736(22)01439-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/20/2022] [Accepted: 07/27/2022] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterised by acute hypoxaemic respiratory failure with bilateral infiltrates on chest imaging, which is not fully explained by cardiac failure or fluid overload. ARDS is defined by the Berlin criteria. In this Series paper the diagnosis, management, outcomes, and long-term sequelae of ARDS are reviewed. Potential limitations of the ARDS definition and evidence that could inform future revisions are considered. Guideline recommendations, evidence, and uncertainties in relation to ARDS management are discussed. The future of ARDS strives towards a precision medicine approach, and the framework of treatable traits in ARDS diagnosis and management is explored.
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Affiliation(s)
- Ellen A Gorman
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Cecilia M O'Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.
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11
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Jain S, Hauschildt K, Scheunemann LP. Social determinants of recovery. Curr Opin Crit Care 2022; 28:557-565. [PMID: 35993295 DOI: 10.1097/mcc.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to examine evidence describing the influence of social determinants on recovery following hospitalization with critical illness. In addition, it is meant to provide insight into the several mechanisms through which social factors influence recovery as well as illuminate approaches to addressing these factors at various levels in research, clinical care, and policy. RECENT FINDINGS Social determinants of health, ranging from individual factors like social support and socioeconomic status to contextual ones like neighborhood deprivation, are associated with disability, cognitive impairment, and mental health after critical illness. Furthermore, many social factors are reciprocally related to recovery wherein the consequences of critical illness such as financial toxicity and caregiver burden can put essential social needs under strain turning them into barriers to recovery. SUMMARY Recovery after hospitalization for critical illness may be influenced by many social factors. These factors warrant attention by clinicians, health systems, and policymakers to enhance long-term outcomes of critical illness survivors.
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12
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McPeake J, Boehm L, Hibbert E, Hauschildt K, Bakhru R, Bastin A, Butcher B, Eaton T, Harris W, Hope A, Jackson J, Johnson A, Kloos J, Korzick K, McCartney J, Meyer J, Montgomery-Yates A, Quasim T, Slack A, Wade D, Still M, Netzer G, Hopkins RO, Mikkelsen ME, Iwashyna T, Haines K, Sevin C. Modification of social determinants of health by critical illness and consequences of that modification for recovery: an international qualitative study. BMJ Open 2022; 12:e060454. [PMID: 36167379 PMCID: PMC9516069 DOI: 10.1136/bmjopen-2021-060454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/11/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Social determinants of health (SDoH) contribute to health outcomes. We identified SDoH that were modified by critical illness, and the effect of such modifications on recovery from critical illness. DESIGN In-depth semistructured interviews following hospital discharge. Interview transcripts were mapped against a pre-existing social policy framework: money and work; skills and education; housing, transport and neighbourhoods; and family, friends and social connections. SETTING 14 hospital sites in the USA, UK and Australia. PARTICIPANTS Patients and caregivers, who had been admitted to critical care from three continents. RESULTS 86 interviews were analysed (66 patients and 20 caregivers). SDoH, both financial and non-financial in nature, could be negatively influenced by exposure to critical illness, with a direct impact on health-related outcomes at an individual level. Financial modifications included changes to employment status due to critical illness-related disability, alongside changes to income and insurance status. Negative health impacts included the inability to access essential healthcare and an increase in mental health problems. CONCLUSIONS Critical illness appears to modify SDoH for survivors and their family members, potentially impacting recovery and health. Our findings suggest that increased attention to issues such as one's social network, economic security and access to healthcare is required following discharge from critical care.
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Affiliation(s)
- Joanne McPeake
- Critical Care, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
- Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Leanne Boehm
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Elizabeth Hibbert
- Department of Physiotherapy, Western Health Foundation, Sunshine, Victoria, Australia
| | - Katrina Hauschildt
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Rita Bakhru
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Anthony Bastin
- Department of Peri-operative Medicine, Barts Health NHS Trust, London, UK
| | - Brad Butcher
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tammy Eaton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy, University of Michigan, Ann Arbor, Michigan, US
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan, US
| | - Wendy Harris
- Intensive Care Unit, University College London, London, UK
| | - Aluko Hope
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA
| | - James Jackson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Annie Johnson
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Janet Kloos
- Department of Acute and Critical Care Nursing, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Karen Korzick
- Department of Pulmonary and Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Joel Meyer
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Tara Quasim
- Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK
| | - Andrew Slack
- Department of Critical Care, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Dorothy Wade
- Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mary Still
- Critical Care, Emory University Hospital, Atlanta, Georgia, USA
| | - Giora Netzer
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care and Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Psychology and Neuroscience, Brigham Young University, Provo, Utah, USA
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Theodore Iwashyna
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan, USA
| | - Kimberley Haines
- Department of Physiotherapy, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Carla Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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13
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Butcher BW, Eaton TL, Montgomery-Yates AA, Sevin CM. Meeting the Challenges of Establishing Intensive Care Unit Follow-up Clinics. Am J Crit Care 2022; 31:324-328. [PMID: 35773186 DOI: 10.4037/ajcc2022987] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Intensive care unit follow-up clinics are becoming an increasingly widespread intervention to facilitate the physical, cognitive, psychiatric, and social rehabilitation of survivors of critical illness who have post-intensive care syndrome. Developing and sustaining intensive care unit follow-up clinics can pose significant challenges, and clinics need to be tailored to the physical, personnel, and financial resources available at a given institution. Although no standard recipe guarantees a successful intensive care unit aftercare program, emerging clinics will need to address a common set of hurdles, including securing an adequate space; assembling an invested, multidisciplinary staff; procuring the necessary financial, information technology, and physical stuff; using the proper screening tools to identify patients most likely to benefit and to accurately identify disabilities during the visit; and selling it to colleagues, hospital administrators, and the community at large.
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Affiliation(s)
- Brad W Butcher
- Brad W. Butcher is an associate professor and director of the Critical Illness Recovery Center, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Tammy L Eaton
- Tammy L. Eaton is a health services researcher with the Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan and a National Clinician Scholars Program postdoctoral VA research fellow with the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Ashley A Montgomery-Yates
- Ashley A. Montgomery-Yates is an associate professor and director of the ICU Recovery Clinic, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, Kentucky
| | - Carla M Sevin
- Carla M. Sevin is an associate professor, director of the Pulmonary Patient Care Center, and director of the ICU Recovery Center, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Improving Post-Injury Care: Key Family Caregiver Perspectives of Critical Illness After Injury. Crit Care Explor 2022; 4:e0685. [PMID: 35558737 PMCID: PMC9084436 DOI: 10.1097/cce.0000000000000685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
There is little research about how caregiver experiences evolve from ICU admission to patient recovery, especially among caregivers for patients who have traumatic injuries. In this study, we characterize diverse caregiver experiences during and after ICU admission for injury.
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15
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Haines KJ. Peer support to improve recovery after critical care for COVID-19. J Physiother 2022; 68:83-85. [PMID: 35382995 PMCID: PMC8976230 DOI: 10.1016/j.jphys.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kimberley J Haines
- Department of Physiotherapy, Western Health, Melbourne, Australia; Department of Critical Care, School of Medicine, The University of Melbourne, Melbourne, Australia.
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16
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17
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Spiritoso R, Crouch M, Bakowski A, Gorgoraptis N, Bastin A. Follow-up for Survivors of Cardiac Critical Illness: Winning Hearts and Minds. J Card Fail 2021; 27:1148-1151. [PMID: 34625133 DOI: 10.1016/j.cardfail.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Rosalba Spiritoso
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Margie Crouch
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Anna Bakowski
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Nikos Gorgoraptis
- Department of Neurology, Barts Health NHS Trust, London, UK; Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Anthony Bastin
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK.
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18
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Connolly B, Milton-Cole R, Adams C, Battle C, McPeake J, Quasim T, Silversides J, Slack A, Waldmann C, Wilson E, Meyer J. Recovery, rehabilitation and follow-up services following critical illness: an updated UK national cross-sectional survey and progress report. BMJ Open 2021; 11:e052214. [PMID: 34607869 PMCID: PMC8491421 DOI: 10.1136/bmjopen-2021-052214] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/31/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To comprehensively update and survey the current provision of recovery, rehabilitation and follow-up services for adult critical care patients across the UK. DESIGN Cross-sectional, self-administered, predominantly closed-question, electronic, online survey. SETTING Institutions providing adult critical care services identified from national databases. PARTICIPANTS Multiprofessional critical care clinicians delivering services at each site. RESULTS Responses from 176 UK hospital sites were included (176/242, 72.7%). Inpatient recovery and follow-up services were present at 127/176 (72.2%) sites, adopting multiple formats of delivery and primarily delivered by nurses (n=115/127, 90.6%). Outpatient services ran at 130 sites (73.9%), predominantly as outpatient clinics. Most services (n=108/130, 83.1%) were co-delivered by two or more healthcare professionals, typically nurse/intensive care unit (ICU) physician (n=29/130, 22.3%) or nurse/ICU physician/physiotherapist (n=19/130, 14.6%) teams. Clinical psychology was most frequently lacking from inpatient or outpatient services. Lack of funding was consistently the primary barrier to service provision, with other barriers including logistical and service prioritisation factors indicating that infrastructure and profile for services remain inadequate. Posthospital discharge physical rehabilitation programmes were relatively few (n=31/176, 17.6%), but peer support services were available in nearly half of responding institutions (n=85/176, 48.3%). The effects of the COVID-19 pandemic resulted in either increasing, decreasing or reformatting service provision. Future plans for long-term service transformation focus on expansion of current, and establishment of new, outpatient services. CONCLUSION Overall, these data demonstrate a proliferation of recovery, follow-up and rehabilitation services for critically ill adults in the past decade across the UK, although service gaps remain suggesting further work is required for guideline implementation. Findings can be used to enhance survivorship for critically ill adults, inform policymakers and commissioners, and provide comparative data and experiential insights for clinicians designing models of care in international healthcare jurisdictions.
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Affiliation(s)
- Bronwen Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rhian Milton-Cole
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Claire Adams
- Department of Anaesthesia & Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ceri Battle
- Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK
| | - Joanne McPeake
- NHS Greater Glasgow and Clyde, Glasgow, UK
- School of Medicine, Dentistry, and Nursing, University of Glasgow, Glasgow, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Tara Quasim
- NHS Greater Glasgow and Clyde, Glasgow, UK
- School of Medicine, Dentistry, and Nursing, University of Glasgow, Glasgow, UK
| | - Jon Silversides
- Department of Critical Care, Belfast Health and Social Care Trust, Belfast, UK
| | - Andrew Slack
- Department of Critical Care, Guy's and St.Thomas' NHS Foundation Trust, London, UK
| | - Carl Waldmann
- Department of Intensive Care and Anaesthetics, Royal Berkshire Hospital, Reading, UK
| | - Elizabeth Wilson
- Department of Critical Care Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Joel Meyer
- Department of Critical Care, Guy's and St.Thomas' NHS Foundation Trust, London, UK
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19
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McPeake J, Sevin CM, Mikkelsen ME. Functional outcomes following critical illness: epidemiology, current management strategies and the future priorities. Curr Opin Crit Care 2021; 27:506-512. [PMID: 34267076 DOI: 10.1097/mcc.0000000000000856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Intensive care unit (ICU) survivorship has gained significant attention over the course of the COVID-19 pandemic. In this review, we summarize the contemporary literature in relation to the epidemiology and management of post-ICU problems. RECENT FINDINGS Survivors of critical illness can have complex physical, social, emotional and cognitive needs in the months following hospital discharge. Emerging evidence has shown that pre-ICU characteristics such as educational attainment, alongside in-ICU factors such as delirium, may contribute to worsening outcomes. Evidence regarding the impact of post-ICU recovery services is evolving, but models such as post-ICU clinics and peer support programs are gaining rapid momentum. SUMMARY Future research should focus on modifiable risk factors and how identification and treatment of these can improve outcomes. Furthermore, rigorous evaluation of postacute critical care recovery services is necessary.
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Affiliation(s)
- Joanne McPeake
- NHS Greater Glasgow and Clyde, University of Glasgow, School of Medicine, Dentistry and Nursing, THIS Institute (University of Cambridge), Cambridge, UK
| | - Carla M Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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20
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Optimizing Critical Illness Recovery: Perspectives and Solutions From the Caregivers of ICU Survivors. Crit Care Explor 2021; 3:e0420. [PMID: 34079948 PMCID: PMC8162533 DOI: 10.1097/cce.0000000000000420] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: To understand the unmet needs of caregivers of ICU survivors, how they accessed support post ICU, and the key components of beneficial ICU recovery support systems as identified from a caregiver perspective. Design: International, qualitative study. Subjects: We conducted 20 semistructured interviews with a diverse group of caregivers in the United States, the United Kingdom, and Australia, 11 of whom had interacted with an ICU recovery program. Setting: Seven hospitals in the United States, United Kingdom, and Australia. Interventions: None. Measurements and Main Results: Content analysis was used to explore prevalent themes related to unmet needs, as well as perceived strategies to improve ICU outcomes. Post-ICU care was perceived to be generally inadequate. Desired caregiver support fell into two main categories: practical support and emotional support. Successful care delivery initiatives included structured programs, such as post discharge telephone calls, home health programs, post-ICU clinics, and peer support groups, and standing information resources, such as written educational materials and online resources. Conclusions: This qualitative, multicenter, international study of caregivers of critical illness survivors identified consistently unmet needs, means by which caregivers accessed support post ICU, and several care mechanisms identified by caregivers as supporting optimal ICU recovery.
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21
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Affiliation(s)
- Aluko A. Hope
- Aluko A. Hope is coeditor in chief of the American Journal of Critical Care. He is an associate professor at Albert Einstein College of Medicine and an intensivist and assistant bioethics consultant at Montefiore Medical Center, both in New York City
| | - Cindy L. Munro
- Cindy L. Munro is coeditor in chief of the American Journal of Critical Care. She is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
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22
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Hope AA, Johnson AA, McPeake J, Felt H, Sevin CM, Mikkelsen ME, Iwashyna TJ, Lassen-Greene C, Haines KJ, Agarwal S, Bakhru RN, Boehm LM, Butcher BW, Drumright K, Eaton TL, Hibbert E, Hoehn KS, Hornstein D, Imperato-Shedden H, Jackson JC, Kloos JA, Lewis A, Meyer J, Montgomery-Yates A, Rojas V, Schorr C, Wade D, Williams C. Establishing a Peer Support Program for Survivors of COVID-19: A Report From the Critical and Acute Illness Recovery Organization. Am J Crit Care 2021; 30:e1-e5. [PMID: 33566061 PMCID: PMC8364567 DOI: 10.4037/ajcc2021675] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Aluko A Hope
- Aluko A. Hope is an associate professor, Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Andrea Annie Johnson
- Andrea (Annie) Johnson is a nurse practitioner, Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joanne McPeake
- Joanne McPeake is a nurse consultant, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Scotland, United Kingdom and a research fellow, THIS Institute, University of Cambridge, United Kingdom
| | - Hali Felt
- Hali Felt is an author and critical care survivor who is working on her second book, titled Extracorporeal: A Memory of Science and Recovery. She lives in Sacramento, California
| | - Carla M Sevin
- Carla M. Sevin is an associate professor, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark E Mikkelsen
- Mark E. Mikkelsen is an associate professor, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia
| | - Theodore J Iwashyna
- Theodore J. Iwashyna is a professor of internal medicine, Department of Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, and a research scientist, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Michigan
| | - Caroline Lassen-Greene
- Caroline Lassen-Greene is an assistant professor, Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center
| | - Kimberley J Haines
- Kimberley J. Haines is the physiotherapy lead and senior ICU physiotherapist, Department of Physiotherapy, Western Health, Sunshine Hospital, St Albans, Australia and an associate professor, Centre for Integrated Critical Care, School of Medicine, The University of Melbourne, Australia
| | - Sachin Agarwal
- Sachin Agarwal is an assistant professor, Department of Neurology (Neurocritical Care), Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Rita N Bakhru
- Rita N. Bakhru is an assistant professor, Section of Pulmonary, Critical Care, Allergy and Immunology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Leanne M Boehm
- Leanne M. Boehm is an assistant professor, School of Nursing, Vanderbilt University, Nashville, Tennessee
| | - Brad W Butcher
- Brad W. Butcher is an assistant professor, Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC), Pennsylvania
| | - Kelly Drumright
- Kelly Drumright is a clinical nurse leader for the medical intensive care unit, Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee
| | - Tammy L Eaton
- Tammy L. Eaton is a PhD candidate at the University of Pittsburgh, School of Nursing, and a founder of the Critical Illness Recovery Center (CIRC) at UPMC Mercy in Pittsburgh, Pennsyvania
| | - Elizabeth Hibbert
- Elizabeth Hibbert is a physiotherapist, Department of Physiotherapy, Western Health, Melbourne, Australia
| | - Karen Sara Hoehn
- Karen Sara Hoehn is director of the Pediatric Palliative Care Team, University of Chicago, Illinois
| | - David Hornstein
- David Hornstein is an assistant professor, McGill University Health Centre, Program of Critical Care and Internal Medicine, Montreal, Québec, Canada
| | - Heather Imperato-Shedden
- Heather Imperato-Shedden is a social worker and family and patient support specialist, Morristown Medical Center, Morristown, New Jersey
| | - James C Jackson
- James C. Jackson is a research professor, Vanderbilt University Medical Center
| | - Janet A Kloos
- Janet A. Kloos is a clinical nurse specialist, Department of Acute and Critical Care Nursing, University Hospitals Cleveland Medical Center, Ohio
| | - Anna Lewis
- Anna Lewis is a senior social worker, CIRC, UPMC Mercy Hospital, Pittsburgh, Pennsylvania
| | - Joel Meyer
- Joel Meyer is a critical care consultant, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - Ashley Montgomery-Yates
- Ashley Montgomery-Yates is an associate professor, Department of Medicine, University of Kentucky
| | - Veronica Rojas
- Veronica Rojas is a critical care nurse leader, Department of Internal Medicine, Hospital Clínico Universidad de Chile, Santiago
| | - Christa Schorr
- Christa Schorr is a clinical nurse scientist and associate professor, Department of Medicine, Division of Critical Care, Cooper Medical School of Rowan University Health Care in New Jersey
| | - Dorothy Wade
- Dorothy Wade is principal health psychologist, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Cydni Williams
- Cydni Williams is an associate professor, Department of Pediatrics, Division of Pediatric Critical Care, Oregon Health & Science University, Portland
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