Providing psychological support to people in intensive care: development and feasibility study of a nurse-led intervention to prevent acute stress and long-term morbidity

This research by Wade and colleagues was published in BMJ Open in July.
Objectives:  Adverse psychological outcomes, following stressful experiences in critical care, affect up to 50% of patients. We aimed to develop and test the feasibility of a psychological intervention to reduce acute stress and prevent future morbidity.
Design:  A mixed-methods intervention development study, using two stages of the UK Medical Research Council framework for developing and testing complex interventions. Stage one (development) involved identifying an evidence base for the intervention, developing a theoretical understanding of likely processes of change and modelling change processes and outcomes. Stage two comprised two linked feasibility studies.
Setting:  Four UK general adult critical care units.
Participants:  Stage one: former and current patients, and psychology, nursing and education experts. Stage two: current patients and staff.
Outcomes:  Feasibility and acceptability to staff and patients of content and delivery of a psychological intervention, assessed using quantitative and qualitative data. Estimated recruitment and retention rates for a clinical trial.
Results:  Building on prior work, we standardised the preventative, nurse-led Provision Of Psychological support to People in Intensive Care (POPPI) intervention. We devised courses and materials to train staff to create a therapeutic environment, to identify patients with acute stress and to deliver three stress support sessions and a relaxation and recovery programme to them. 127 awake, orientated patients took part in an intervention feasibility study in two hospitals. Patient and staff data indicated the complex intervention was feasible and acceptable. Feedback was used to refine the intervention. 86 different patients entered a separate trial procedures study in two other hospitals, of which 66 (80% of surviving patients) completed questionnaires on post-traumatic stress, depression and health 5 months after recruitment.
Conclusion:  The ‘POPPI’ psychological intervention to reduce acute patient stress in critical care and prevent future psychological morbidity was feasible and acceptable. It was refined for evaluation in a cluster randomised clinical trial.
The full text of this article in BMJ open is available via this link.

Critical Care Reviews Newsletter 346 29th July 2018

Welcome to the 346th Critical Care Reviews Newsletter, bringing you the best critical care research and open access articles from across the medical literature over the past seven days.  ”The highlights of this week’s edition are randomised controlled trials on the prehospital use of plasma during air medical transport of trauma patients & in-bed leg cyccritcal care reviewsling and muscle electrical stimulation; systematic reviews and meta analyses on red blood cell transfusion in patients with ST-elevation myocardial infarction & the association of hyperoxia with mortality in critically ill patients; plus an observational study on the association between the New York Sepsis Care Mandate and in-hospital mortality in pediatric sepsis. There is also a Japanese guideline on acute kidney injury.”

The full text of the newsletter can be accessed via this link.

Attention-seeking actions by patients on mechanical ventilation in intensive care units: A qualitative study

This article by Wallander was published in the July 2018 issue of the Journal of Clinical Nursing.
Aims and Objectives:  The aim of this study was to explore the interaction between mechanically ventilated patients and healthcare personnel in intensive care units, with a special emphasis on patients’ initiative to communicate.
Background:  Patients on mechanical ventilation in intensive care units tend to be less sedated today compared to standard care in the past. Their experiences of being voiceless may cause emotional distress, and for many patients, communication is difficult. Healthcare personnel are reported to be the main initiators of the communication exchanges that occur.
Design:  An observational study with a phenomenological-hermeneutical approach.
Methods:  Video recording was used to collect data on the naturally occurring communication and interaction. Ten conscious and alert patients from two Norwegian intensive care units were recruited. Two relatives and a total of sixty healthcare personnel participated. Content analysis was conducted, with focus on both the manifest and latent content meaning.
Results:  We found a total of 66 situations in which patients attempted to attract the attention of others on their own initiative in order to express themselves. Attention-seeking actions, defined as the act of seeking attention and understanding without a voice, became an essential theme. Four patterns of interaction were identified: immediately responded to, delayed response or understanding, intensified attempts, or giving up. Patients had a variety of reasons for seeking attention, which were classified into four domains: psychological expressions, physical expressions, social expressions, and medical treatment.
Conclusions:  Patients’ attention-seeking actions varied in content, form, and the types of responses they elicited. The patients had to fight to first gain joint attention and then joint understanding. This was both energy draining and time consuming.
Relevance to Clinical Practice:  Healthcare personnel need to spend more time for communication purposes, giving attention and being more alert to bodily or symbolic gestures to understand the patient’s needs. This article is protected by copyright. All rights reserved.
To access the full text of this article via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

A Mixed Methods Study of Tele-ICU Nursing Interventions to Prevent Failure to Rescue of Patients in Critical Care

This article by Williams et al was published in “Telemedicine journal and e-health” in July 2018.
Background:  Failure to rescue (FTR) is a benchmark of quality care. Limited evidence exists examining the influence of telemedicine intensive care units (tele-ICU) nursing interventions in preventing FTR. The purpose of this study was to characterize tele-ICU nursing interventions and to determine which combination of documented tele-ICU nursing interventions (DTNI) best predicts prevention of FTR in ICU patients with hospital-acquired conditions (HACs).
Materials and Methods:  We used convergent parallel mixed methods design to conduct qualitative interviews with a purposive sample of tele-ICU nurses (n = 19) from 11 US tele-ICU centers. Quantitative data, including demographics, DTNIs, severity of illness scores, and video assessment times from January 2016 to December 2016 were retrieved for ICU patients discharged from a multihospital health system with a tele-ICU center (n = 861). Findings from both qualitative and quantitative analyses were merged, compared, and contrasted.
Results:  FTR patients had higher severity of illness, longer video assessment by tele-ICU nurses, and were more likely to have DTNIs related to hemodynamic instability. Four themes emerged from qualitative analysis: fundamental tele-ICU nurse attributes, proactive clinical practice, effective collaborative relationships, and strategic use of advanced technology. Mixed methods analysis revealed convergence between DTNIs and tele-ICU nurses’ characterizations of their practice.
Conclusions:  Tele-ICU nurses’ characterizations of their practice closely align with DTNIs. Tele-ICU nursing practice to prevent FTR involves systems thinking and integration of many complex factors. Tele-ICU nurses can reduce the odds of FTR with focus on support and clinical coordination interventions that avoid hemodynamic instability in ICU patients with a diagnosed HAC.
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Critical Care Reviews Newsletter 345 22nd July 2018

The Critical Care Reviews Newsletter “brings you the best critical care research and open access articles from across the medical literature over the past seven days.”  “The big news this week is the publication of the landmark PARAMEDIC2 trial, comparing adrenaline with placebo in out-of-hospital cardiac arrest”.  Also included are other randomised controlled trials including “Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area”, systematic reviews such as “Neurologic Outcomes after Extracorporeal Membrane Oxygenation Assisted CPR for Resuscitation of Out-of-Hospital Cardiac Arrest Patients” and guidelines including “European Association for the Study of the Liver Clinical Practice Guidelines for the management of patients with decompensated cirrhosis.”
The full text of the newsletter can be accessed via this link.

Intensive Care Medicine Volume 44 Number 7 July 2018

intensive-care-medicine

To view Intensive Care Medicine’s July issue’s contents page follow this link.
Articles published in this issue include: “Prevalence and risk factors related to haloperidol use for delirium in adult intensive care patients: the multinational AID-ICU inception cohort study”, “Circulating biomarkers may be unable to detect infection at the early phase of sepsis in ICU patients: the CAPTAIN prospective multicenter cohort study” and “Out-of-hours discharge from intensive care, in-hospital mortality and intensive care readmission rates: a systematic review and meta-analysis“.
To read the full text of any of these articles via the journal’s homepage requires a personal subscription to “Intensive Care Medicine” though some are available open access.  Individual articles can be ordered from the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.
The full text of articles from issues older than one year ago is available via this link to an archive of issues of Intensive Care Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Speaking up about care concerns in the ICU: patient and family experiences, attitudes and perceived barriers

This research by Bell and others was published in BMJ Quality and Safety July 2018 issue.
Background:  Little is known about patient/family comfort voicing care concerns in real time, especially in the intensive care unit (ICU) where stakes are high and time is compressed. Experts advocate patient and family engagement in safety, which will require that patients/families be able to voice concerns. Data on patient/family attitudes and experiences regarding speaking up are sparse, and mostly include reporting events retrospectively, rather than pre-emptively, to try to prevent harm. We aimed to (1) assess patient/family comfort speaking up about common ICU concerns; (2) identify patient/family-perceived barriers to speaking up; and (3) explore factors associated with patient/family comfort speaking up.
Methods:  In collaboration with patients/families, we developed a survey to evaluate speaking up attitudes and behaviours. We surveyed current ICU families in person at an urban US academic medical centre, supplemented with a larger national internet sample of individuals with prior ICU experience.
Results:  105/125 (84%) of current families and 1050 internet panel participants with ICU history completed the surveys. Among the current ICU families, 50%-70% expressed hesitancy to voice concerns about possible mistakes, mismatched care goals, confusing/conflicting information and inadequate hand hygiene. Results among prior ICU participants were similar. Half of all respondents reported at least one barrier to voicing concerns, most commonly not wanting to be a ‘troublemaker’, ‘team is too busy’ or ‘I don’t know how’. Older, female participants and those with personal or family employment in healthcare were more likely to report comfort speaking up.
Conclusion:  Speaking up may be challenging for ICU patients/families. Patient/family education about how to speak up and assurance that raising concerns will not create ‘trouble’ may help promote open discussions about care concerns and possible errors in the ICU.
The full text of this article is available via this link to an archive of issues of Intensive Care Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Patients admitted via the emergency department to the intensive care unit: An observational cohort study.

This observational study was undertaken by Crilly and colleagues and published un the July 2018 issue of Emergency Medicine Australasia.
Objective:  Timely and appropriate assessment and management within the ED impacts patient outcomes including in-hospital mortality and length of stay (LOS). Within the ED, several processes facilitate timely recognition of the need for intensive care unit (ICU) admission. This study describes characteristics and outcomes for patient presentations admitted to ICU from ED, categorised by Australasian Triage Score (ATS), ICU admission time and ICU admission source.
Methods:  A retrospective observational cohort study with linked health data of adult ICU admissions during 2012. Outcomes measured included: ED, ICU and hospital LOS, time to see ED clinician, ICU readmission and ICU and hospital mortality rates.
Results:  In total, 423 ICU admissions occurred within 24 h of ED arrival; 395 were admitted directly to ICU; 28 were admitted to the ward before ICU admission. ATS 3/4/5 patients comprised 26.7% of ICU admissions and experienced longer waits to be seen, longer total ED LOS, shorter ICU LOS and a lower mortality rate than those triaged ATS 1/2. Compared to ICU admissions during business hours, admissions outside hours did not differ significantly for any outcome measured. Patients admitted to the ward before ICU experienced longer waits to be seen and longer ED LOS.
Conclusion:  Most patients are appropriately identified in ED as requiring ICU admission, although around one in four were triaged ATS 3/4. Patients admitted to the ward first tended to have poorer outcomes than those directly admitted to ICU. Factors predicting the need for ICU admission should be identified to support clinical decision-making.
To access the full text of this article via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Characteristics and outcomes of patients with hematologic malignancies receiving chemotherapy in the intensive care unit.

This research by Pastores and colleagues was published in the July issue of the journal Cancer.
Background:  The objective of this study was to evaluate the short-term and long-term outcomes of adult patients with hematologic malignancies who received chemotherapy in the intensive care unit (ICU).
Methods:  This was a retrospective, single-center study comparing the outcomes of patients with hematologic malignancies who received chemotherapy in the ICU with a matched cohort of ICU patients who did not receive chemotherapy. Conditional logistic regression and shared-frailty Cox regression were used to assess short-term (ICU and hospital) mortality and death by 12 months after hospital discharge, respectively.
Results:  One hundred eighty-one patients with hematologic malignancies received chemotherapy in the ICU. The ICU and hospital mortality rates were 25% and 42% for chemotherapy patients and 22% and 33% for non-chemotherapy patients, respectively. Higher severity of illness scores on ICU admission were significantly associated with higher ICU mortality (odds ratio, 1.07; P < .001) and hospital mortality (odds ratio, 1.05; P ≤ .001). Six-month and 12-month survival estimates posthospital discharge were 58% and 50%, respectively. Compared with the matched cohort of patients who did not receive chemotherapy, those who did receive chemotherapy had a significantly longer length of stay in the ICU (median, 6 vs 3 days; P < .001) and in the hospital (median, 22 vs 14 days; P = .024). In multivariable analysis, the patients who received chemotherapy in the ICU had a trend toward a higher risk of dying by 12 months (hazard ratio, 1.45; P = .08).
Conclusions:  Short-term mortality was similar among patients with hematologic malignancies who did and did not receive chemotherapy in the ICU, although patients who received chemotherapy had increased resource utilization. These results may inform ICU triage and goals-of-care discussions with patients and their families regarding outcomes after receiving chemotherapy in the ICU.
To access the full text of this article via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Feasibility of Telemetric Intracranial Pressure Monitoring in the Neuro Intensive Care Unit

This article by LilijCyron and colleagues was published in Journal of Neurotrauma in July 2018.
Intracranial pressure (ICP) monitoring is crucial in the management of acute neurosurgical conditions such as traumatic brain injury (TBI). However, pathological ICP may persist beyond the admission to the neuro intensive care unit (NICU). We investigated the feasibility of telemetric ICP monitoring in the NICU, as this technology provides the possibility of long-term ICP assessment beyond NICU discharge. In this prospective investigation, we implanted telemetric ICP sensors (Raumedic Neurovent-P-tel) instead of conventional, cabled ICP sensors in patients undergoing decompressive craniectomy. We recorded ICP curves, duration of ICP monitoring, signal quality, and complications. Seventeen patients were included (median age 55 years) and diagnoses were: severe TBI (8), malignant middle cerebral artery infarction (8), and spontaneous intracerebral hemorrhage (1). In total, 3015 h of ICP monitoring were performed, and the median duration of ICP monitoring was 188 h (interquartile range [IQR] 54-259). The ICP signal was lost 613 times (displacement of the reader unit on the skin) for a median of 1.5 min, corresponding to 0.8% of the total monitoring period. When the signal was lost, it could always be restored by realignment of the reader unit on the skin above the telemetric sensor. Sixteen of 17 patients survived the NICU admission, and ICP gradually decreased from 10.7 mm Hg (IQR 7.5-13.6) during the first postoperative day to 6.3 mm Hg (IQR 4.0-8.3) after 1 week in the NICU. All 17 implanted telemetric sensors functioned throughout the NICU admission, and no wound infections were observed. Therefore, telemetric ICP monitoring in an acute neurosurgical setting is feasible. Signal quality and stability are sufficient for clinical decision making based on mean ICP. The low sampling frequency (5 Hz) does not permit analysis of intracranial pulse wave morphology, but resolution is sufficient for calculation of derived indices such as the pressure reactivity index (PRx).
To access the full text of this article via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.