Mental Health Provision in PICU: An Analysis of Referrals to an Embedded Psychologist Over 20 Years at a Single Center

OBJECTIVES

The main aim of this study was to illustrate the type of mental health provision possible on PICU by describing the nature of referrals of child patients and their parents to an embedded psychologist over a 20-year period, adding to the literature on intervention and service development.

DESIGN

Retrospective evaluation of anonymized departmental database.

SETTING

Twelve-bed PICU at a teaching hospital in a major urban center.

PATIENTS

Five hundred forty-five consecutive referrals for support for parent and/or child by PICU staff between 1998 and 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Referrals increased from seven of 288 (2.4%) in 1998 to 85 of 643 (13.2%) in 2017. The majority were for parent support initially (456/545, 84%). Mean ( sd ) number of contacts was 4.5 (10.2), range 1 to 143, and mode was 1. Patient gender and age typical of the total PICU population, but referrals were more common where children had an oncology or trauma diagnosis ( p < 0.001). Comparisons with other inpatient referrals at the same hospital revealed a higher proportion of requests were made for parent support on PICU (456/545 [84%] vs 789/1,997 [40%]; p < 0.001) and that nurses were more likely to initiate referrals on PICU than on the other wards (437/543 [80%] vs 1,190/1,993 [60%]; p < 0.001). In other respects, the two groups were similar in terms of number of sessions, waiting times, and attendance rates.

CONCLUSIONS

Growing appreciation of the psychological impact of a child's admission to PICU has been associated with increasing referral to an embedded psychologist over a 20-year period, at this center. Clinical and service implications are outlined in the context of the latest research on the mitigation of post-intensive care syndrome in this population.

Early mobilisation and rehabilitation in the PICU: a UK survey

OBJECTIVE

To understand the context and professional perspectives of delivering early rehabilitation and mobilisation (ERM) within UK paediatric intensive care units (PICUs).

DESIGN

A web-based survey administered from May 2019 to August 2019.

SETTING

UK PICUs.

PARTICIPANTS

A total of 124 staff from 26 PICUs participated, including 22 (18%) doctors, 34 (27%) nurses, 28 (23%) physiotherapists, 19 (15%) occupational therapists and 21 (17%) were other professionals.

RESULTS

Key components of participants' definitions of ERM included tailored, multidisciplinary rehabilitation packages focused on promoting recovery. Multidisciplinary involvement in initiating ERM was commonly reported. Over half of respondents favoured delivering ERM after achieving physiological stability (n=69, 56%). All age groups were considered for ERM by relevant health professionals. However, responses differed concerning the timing of initiation. Interventions considered for ERM were more likely to be delivered to patients when PICU length of stay exceeded 28 days and among patients with acquired brain injury or severe developmental delay. The most commonly identified barriers were physiological instability (81%), limited staffing (79%), sedation requirement (73%), insufficient resources and equipment (69%), lack of recognition of patient readiness (67%), patient suitability (63%), inadequate training (61%) and inadequate funding (60%). Respondents ranked reduction in PICU length of stay (74%) and improvement in psychological outcomes (73%) as the most important benefits of ERM.

CONCLUSION

ERM is gaining familiarity and endorsement in UK PICUs, but significant barriers to implementation due to limited resources and variation in content and delivery of ERM persist. A standardised protocol that sets out defined ERM interventions, along with implementation support to tackle modifiable barriers, is required to ensure the delivery of high-quality ERM.

Screening for Factors Influencing Parental Psychological Vulnerability During a Child's PICU Admission

OBJECTIVES

To identify the risks of developing post-traumatic stress disorder (PTSD) and/or depression in parents following their child's PICU admission using a brief screening instrument and to examine the associations with these risks.

DESIGN

A cross-sectional parental survey.

SETTING

A general 13-bed PICU at a large teaching hospital.

SUBJECTS

One hundred and seven parents of 75 children admitted to the PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All parents completed the 10-item Posttraumatic Adjustment Screen (PAS) before discharge. The PAS assesses risk factors known to be associated with poorer psychological outcome, including psychosocial variables pretrauma and peritrauma, and acute stress. Parents' scores on the PAS indicated that 64 (60%) were at risk of developing PTSD and 80 (75%) were at risk of developing depression following their child's admission. Univariate analyses suggested that psychosocial variables, such as preexisting stressors and a history of previous mental health problems, were more strongly associated with PAS risk scores for PTSD and depression than medical or sociodemographic factors. In logistic regression analyses, a history of previous mental health problems was significantly associated with risk of developing PTSD and depression (p < 0.001) explaining 28% and 43% of the variance in these outcomes.

CONCLUSIONS

This study suggests that a significant number of parents on PICU are potentially at risk of developing PTSD and/or depression postdischarge and that psychosocial factors, pretrauma and peritrauma, are stronger determinants of this risk, and of acute distress, than other variables. Identification of vulnerable parents during admission, using a measure such as the PAS, could facilitate the targeting of support and monitoring, acutely and postdischarge, at those who might be most likely to benefit.

Psychological impact of working in paediatric intensive care. A UK-wide prevalence study

OBJECTIVE

To determine the prevalence of work-related psychological distress in staff working in UK paediatric intensive care units (PICU).

DESIGN

Online (Qualtrics) staff questionnaire, conducted April to May 2018.

SETTING

Staff working in 29 PICUs and 10 PICU transport services were invited to participate.

PARTICIPANTS

1656 staff completed the survey: 1194 nurses, 270 physicians and 192 others. 234 (14%) respondents were male. Median age was 35 (IQR 28-44).

MAIN OUTCOME MEASURES

The Moral Distress Scale-Revised (MDS-R) was used to look at moral distress, the abbreviated Maslach Burnout Inventory to examine the depersonalisation and emotional exhaustion domains of burnout, and the Trauma Screening Questionnaire (TSQ) to assess risk of post-traumatic stress disorder (PTSD).

RESULTS

435/1194 (36%) nurses, 48/270 (18%) physicians and 19/192 (10%) other staff scored above the study threshold for moral distress (≥90 on MDS-R) (χ² test, p<0.00001). 594/1194 (50%) nurses, 99/270 (37%) physicians and 86/192 (45%) other staff had high burnout scores (χ² test, p=0.0004). 366/1194 (31%) nurses, 42/270 (16%) physicians and 21/192 (11%) other staff scored at risk for PTSD (χ² test, p<0.00001). Junior nurses were at highest risk of moral distress and PTSD, and junior doctors of burnout. Larger unit size was associated with higher MDS-R, burnout and TSQ scores.

CONCLUSIONS

These results suggest that UK PICU staff are experiencing work-related distress. Further studies are needed to understand causation and to develop strategies for prevention and treatment.

A survey of moral distress in staff working in intensive care in the UK

Elevated rates of burnout and post-traumatic stress have been found in staff working in critical care settings, but the aspect of moral distress has been harder to quantify until a recent revision of a scale previously designed for nurses, was adapted for use with a range of health professionals, including physicians. In this cross-sectional survey, n = 171 nurses and physicians working in intensive care in the United Kingdom completed the Moral Distress Scale-Revised in relation to their experiences at work. Mean (SD) Moral Distress Scale-Revised score was 70.2 (39.6). Significant associations were found with female gender (female 74.1 (40.2) vs. male 55.5 (33.8), p = 0.010); depression (r = 0.165, p = 0.035) and with intention to leave job (considering leaving 85.5 (42.4) vs. not considering leaving 67.2 (38.6), p = 0.040). These results highlight the importance of considering the moral impact of work-related issues when addressing staff wellbeing in critical care settings.

Psychological Aspects of Care of the Critically Ill Child

Recent improvements in mortality rates in pediatric intensive care have led to an increasing focus on the physical and psychological morbidity of pediatric patients. In this review, guidance on the acute psychological management of children, during and shortly after their intensive care treatment, is provided. This is informed by the current state of knowledge regarding the nature of children's experiences of intensive care and the expanding literature on their subsequent psychological symptoms. The relevance to pediatric settings of the current debate about the significance of delirium, and other recent research and guidance regarding the management of psychological issues in adult intensive care settings, is considered. The importance of distinguishing between children's self-report and parents' proxy report is also discussed in relation to establishing the causes of the child's distress in this situation and suggestions are made of ways to help children better understand what has happened to them.

Mothers’ recollections of the Paediatric Intensive Care Unit: Associations with psychopathology and views on follow up

The aim of this study was to establish rates of posttraumatic stress symptoms in mothers after a child's admission to a Paediatric Intensive Care Unit (PICU) and their views on the potential value of a follow up appointment with PICU staff. Thirty-four mothers completed the Parental Stressor Scale:PICU, the General Health Questionnaire (GHQ-28) and the Impact of Event Scale, 8 months after discharge. In total 18/34 (53%) scored > or =5 on the GHQ-28 and 6/32 (18%) of the sample scored in the severe range (>35) on the Impact of Event Scale. Distress was associated with retrospective reports of stress experienced during admission (p < 0.001) but not with other demographic or medical variables. Mothers who talked about their feelings at the time of the admission had lower posttraumatic stress scores at 8 months (p = 0.02) and 25/34 (74%) mothers would have appreciated the offer of a follow up appointment. Screening for distress during admission with the Parental Stressor Scale:PICU may identify those mothers in greatest need of psychological support. Mothers' recollections of the Paediatric Intensive Care Unit: Associations with psychopathology and views on follow up.

Psychological management of two cases of self injury on the paediatric intensive care unit

Self injury has not been previously reported in an intensive care setting. Two cases are presented of ventilator dependent children with high spinal cord lesions who exhibited an unusual form of self mutilation, namely lip biting. The key to extinguishing this behaviour was to address the children's psychological needs.

Sleep problems in children with Sanfilippo syndrome

Sanfilippo syndrome is a rare degenerative disorder which has severe intellectual and behavioural sequelae, commonly including sleep problems. A parental questionnaire was used to gather information on the sleep patterns of 80 children with Sanfilippo syndrome (mean age 10 years 2 months). The majority were found to have sleep problems (78%). Many also exhibited other distressing and unusual night time behaviours (staying up all night, chewing the bedclothes or crying out suddenly), and a few laughed or sang. Such problems may have been more severe in those with Sanfilippo syndrome type B. In four of the families offered individually tailored behaviour-management advice there was immediate improvement, which was maintained at followup in two cases. These results demonstrate the usefulness of even such a minimal intervention, even in a very difficult population such as this.

Early presentation in the mucopolysaccharide disorders

The findings of an international questionnaire study of 258 children, affected by the four main subtypes of mucopolysaccharidosis, are presented. Questionnaires were completed by a parent or main carer and all subjects were alive at the time of contact and suffering from Hurler, Hunter, Sanfilippo or Morquio syndrome. A significant proportion of parents of Hurler children (24%) were unaware that anything was wrong with their baby before diagnosis but a larger number (45%) had felt concerned about their child's appearance. Similarly, in the case of the Morquio children, in 75% of cases, parents had been worried about some aspect of their child's physical appearance. In contrast, it was frequently delayed or regressing language which alerted parents of Sanfilippo (56%) and Hunter (32%) children, and this was associated with behaviour problems in 43% of Sanfilippo cases. There were many cases of delayed diagnosis, often occurring more than 2 years after concerns were first raised.

Behaviour in mucopolysaccharide disorders

This paper reports a study of the nature and prevalence of behaviour problems in 258 children with mucopolysaccharide disorders. Questionnaire data obtained through the post was supplemented by home visits to 42 families in the sample and by regular discussions with families at meetings of the Society for Mucopolysaccharide Diseases. High rates of behaviour problems were found, particularly in children with Sanfilippo's and Hunter's disease aged 5 to 9 years. These included destructiveness, restlessness, and aggressiveness. Sleep problems were common across subtypes with an overall prevalence of 66%. Parents reported that they received little or no support in the management of these difficult behaviours. It is concluded that behaviour problems are a primary feature of the mucopolysaccharide disorders and place a major strain on families. Services to help families cope with these problems are urgently needed.