Physical,social, mental and spiritual functioning of COVID-19 intensive care unit-survivors and their family members one year after intensive care unit-discharge: A prospective cohort study

ObjectiveTo describe the long-term functioning of patients who survived a COVID-19-related admission to the intensive care unit and their family members, in the physical, social, mental and spiritual domain.DesignA single-centre, prospective cohort study with a mixed-methods design.SettingThe intensive care unit of the University Medical Center Groningen in the Netherlands.Main outcome measuresTo study functioning 12 months after intensive care discharge several measurements were used, including a standardised list of physical problems, the Clinical Frailty Scale, the Medical Outcomes Study Short-Form General Health Survey, the McMaster Family Assessment Device, the Hospital Anxiety and Depression Scale, and the Spiritual Needs Questionnaire, as well as open questions and interviews with survivors and their family members.ResultsA total of 56 survivors (77%) returned the 12-month questionnaire, whose median age was 62 (inter-quartile range [IQR]: 55.0–68.0). Moreover, 67 family members (66%) returned the 12-month questionnaire, whose median age was 58 (IQR: 43–66). At least one physical problem was reported by 93% of the survivors, with 22% reporting changes in their work-status. Both survivors (84%) and their family members (85%) reported at least one spiritual need. The need to feel connected with family was the strongest. The main theme was ‘returning to normal’ in the interviews with survivors and ‘if the patient is well, I am well’ in the interviews with family members.ConclusionsOne year after discharge, both COVID-19 intensive care survivors and their family members positively evaluate their health-status. Survivors experience physical impairments, and their family members’ well-being is strongly impacted by the health of the survivor.     

Aloud real- time reading of intensive care unit diaries: A feasibility study

ObjectivesMemories of frightening/delusional intensive care unit experiences are a major risk factor for subsequent psychiatric morbidity of critical illness survivors; factual memories are protective. Systematically providing factual information during initial memory consolidation could mitigate the emotional character of the formed memories. We explored feasibility and obtained stakeholder feedback of a novel approach to intensive care unit diaries whereby entries were read aloud to the patients right after they were written to facilitate systematic real time orientation and formation of factual memories.Research methodologyProspective interventional pilot study involving reading diary entries aloud. We have also interviewed involved stakeholders for feedback and collected exploratory data on psychiatric symptoms from patients right after the intensive care stay.SettingVarious intensive care units in a single academic center.Main outcome measuresFeasibility was defined as intervention delivery on ≥80% of days following patient recruitment. Content analysis was performed on stakeholder interview responses. Questionnaire data were compared for patients who received real-time reading to the historical cohort who did not.ResultsOverall, 57% (17 of 30) of patients achieved the set feasibility threshold. Following protocol adjustment, we achieved 86% feasibility in the last subset of patients. Patients reported the intervention as comforting and appreciated the reorientation aspect. Nurses overwhelmingly liked the idea; most common concern was not knowing what to write. Some therapists were unsure whether reading entries aloud might overwhelm the patients. There were no significant differences in psychiatric symptoms when compared to the historic cohort.ConclusionWe encountered several implementation obstacles; once these were addressed, we achieved set feasibility target for the last group of patients. Reading diary entries aloud was welcomed by stakeholders. Designing a trial to assess efficacy of the intervention on psychiatric outcomes appears warranted.Implications for Clinical PracticeThere is no recommendation to change current practice as benefits of the intervention are unproven.     

Psychiatric outcome following paediatric intensive care unit (PICU) admission: a cohort study

Objective To determine whether paediatric intensive care unit (PICU) admission is associated with greater psychiatric morbidity in children and parents as compared with general paediatric ward admissions.Design Retrospective cohort study.Setting Paediatric intensive care unit and two general paediatric wards of a London teaching hospital.Participants Children aged 5–18 years discharged from PICU (exposed cohort) and general paediatric wards (unexposed cohort) 6–12 months previously, together with their parents.Measurements and results Children: the Clinician Administered Post Traumatic Stress Disorder (PTSD) Scale for Children (CAPS-C), the Impact of Event Scale (IES), Strengths and Difficulties Questionnaire, Birleson Depression Scale, Revised Childrens Manifest Anxiety Scale, Child Somatization Inventory. Parents: IES, General Health Questionnaire, Beck Depression Inventory, Hospital Anxiety and Depression Scale. Thirty-five of 46 (76%) PICU-discharged families and 33 of 41 (80%) from general paediatric wards participated. Valid CAPS-C data were obtained for 19 PICU-admitted children and 27 children admitted only to the general paediatric ward; 4/19 (21%) of PICU-discharged children developed PTSD (compared with none of 27 ward admissions), p=0.02. PICU children had significantly more PTSD features of irritability and persistent avoidance of reminders of the admission. Parents of PICU children were more likely to screen positive for PTSD (9/33 (27%) compared with 2/29 (7%) parents of ward-admitted children), p=0.04. There were no significant differences between the groups for other measures of psychopathology.Conclusion Post traumatic stress disorder diagnosis and symptomatology is significantly more common in families where a child has been admitted to the PICU. Consideration should be given to providing psychological support for children and parents after PICU admission.     

Oral intake evaluation in patients following critical illness: an ICU cohort study

Timely and adequate nutrition improves health outcomes for the critically ill patient. Despite clinical guidelines recommending early oral nutrition, survivors of critical illness experience significant nutritional deficits. This cohort study evaluates the oral nutrition intake in intensive care unit (ICU) patients who have experienced recent critical illness. The oral nutrition intake of a convenience sample of ICU patients post‐critical illness was observed during a 1‐month period. Data pertaining to both the amount of oral nutrition intake and factors impacting optimal oral nutrition intake were collected and analysed. Inadequate oral intake was identified in 62% of the 79 patients assessed (n = 49). This was noted early in the ICU stay, around day 1–2, for most of the patients. A significant proportion (25%) of patients remained in the hospital with poor oral intake that persisted beyond ICU day 5. Unsurprisingly, these were the patients who had longer ICU stays. Critical illness weakness was a factor in the assessment of poor oral intake. To conclude, patients who have experienced critical illness also experience suboptimal oral nutrition. The three key factors that were identified as impacting optimal oral nutrition were early removal of nasogastric tubes, critical illness weakness and poor appetite post‐critical illness. Seven key recommendations are made based on this cohort study. These recommendations are related to patient assessment, monitoring, documentation and future guidelines. Future research opportunities are highlighted, including the investigation of strategies to improve the transition of patients' post‐critical illness to oral nutrition.     

Mode of death after admission to an intensive care unit following cardiac arrest

Objective To determine the mode of death in patients admitted to an intensive care unit (ICU) after cardiac arrest who died before hospital discharge.Design Prospectively defined retrospective review of a database and individual patient medical records and ICU charts.Setting Eleven-bed multidisciplinary intensive care unit in a general hospital in the United Kingdom.Patients and participants All patients admitted to ICU between February 1998 and July 2003 after a cardiac arrest in the previous 24 h.Measurements and results The outcome at hospital discharge and mode of death in non-survivors were recorded. Based on the mode of death, non-survivors were placed in one of three groups: multiple organ failure death, neurological death or cardiovascular death. Two hundred and five patients were admitted to ICU after a cardiac arrest; 113 (55.1%) after out-of-hospital cardiac arrest and 92 (44.9%) after in-hospital cardiac arrest. One hundred and twenty-six (61.5%) patients died before hospital discharge and of these 58 (46.0%) died due to neurological injury. After cardiac arrest, 22.9% of the in-hospital patients and 67.7% of the out-of-hospital patients died due to neurological injury, irrespective of the primary cardiac arrest arrhythmia.Conclusions Two-thirds of the patients dying after out-of-hospital cardiac arrest died due to neurological injury and this proportion was approximately the same for ventricular fibrillation/ventricular tachycardia and pulseless electrical activity/asystole. Approximately a quarter of the patients dying after in-hospital cardiac arrest died due to neurological injury.     

Impact of oral care on thirst perception and dry mouth assessments in intensive care patients: An observational study

ObjectivesTo investigate the impact of oral care on thirst perception and dry mouth assessments.Research designSingle-centre observational study.SettingIntensive care unit in a university hospital.Main OutcomeWe assessed thirst perception and dry mouth in adult patients before and after oral care. Thirst perception was assessed using a numerical rating scale and dry mouth was assessed using an oral moisture checking device and the modified Revised Oral Assessment Guide including tongue, mucous membranes and saliva.ResultsEighty-six patients were included. After oral care, thirst scores decreased by 1 (0 to 3, p < 0.01) and remained low only for one hour. Oral moisture was maintained at a normal level ≥ 27.0%, and mROAG was at a low level ≤ 4 before and after the oral care. The numerical rating score did not correlate with oral moisture (ρ = −0.01, p = 0.96) or the modified revised oral assessment guide (ρ = 0.09, p = 0.42). Among patients with thirst, 60 (70%) patients complained of thirst at the assessment timepoints, but only 17 (20%) patients complained independently.ConclusionThirst perception was dissociated from dry mouth before and after oral care. Thirst must be frequently assessed and treated.     

A national survey of intensive care follow-up clinics in Australia

BackgroundIntensive care follow-up clinics (ICFCs) have been implemented internationally with the aim to address the growing number of patients living with sequalae of critical illness and intensive care. However, data on Australian intensive care follow-up practice are rare.ObjectivesThe primary objective was to determine the proportion of Australian intensive care units (ICUs) that offer a dedicated ICFC to ICU survivors, with the intention of improving long-term outcomes of critical illness. Secondary objectives were to identify models of ICU follow-up and barriers to the implementation of ICFCs.MethodsA custom-designed, pilot-tested 12-question online survey was sent to the nurse unit managers and medical directors of all 167 Australian ICUs listed in the database of the Australian and New Zealand Intensive Care Society. Outcome measures included proportion of ICUs offering ICFCs, details on types of follow-up services with staffing, funding source, and reasons for not providing ICU follow-up.ResultsOne hundred seven of the 167 ICUs contacted responded to the survey. Of these, two (2%) operated a dedicated ICFC. Both ICFCs were nursing-led, with one receiving dedicated funding and the other being unfunded. Three units (3%) conducted routine outpatient follow-up by telephone; one of these services was doctor-led, and two were nurse-led. Four units (4%) were performing outpatient follow-up as part of research studies only. Among the units not operating an ICFC, the main reason given for not doing so were financial constraints (58%), followed by lack of clinical need (19%) and perceived lack of evidence (11%).ConclusionIn Australia, only two ICUs operated an ICFC. Only one outpatient follow-up service received dedicated funding, and financial constraints were the main reason given for units not offering outpatient follow-up services.     

Pressure ulcer prevalence in intensive care patients: a cross-sectional study

Background  Pressure ulcers are a potential complication for intensive care patients and their prevention is a major issue in nursing care. Therefore, this study aims to assess pressure ulcer prevalence in intensive care patients, patients' characteristics and preventive measures related to pressure ulcer prevalence in intensive care patients and to determine the most common body sites of pressure ulcers.
Method  The research design was a cross-sectional study. The sample consisted of 1760 patients (298 in 2002, 408 in 2003, 453 in 2004, 368 in 2005 and 233 participants in 2006) from surgical, medical and interdisciplinary intensive care.
Results  The results revealed a mean prevalence rate of ±30% from 2002 to 2005 while it considerably decreased down to 16.2% in 2006. Half of the pressure ulcers were of grade 1. Furthermore, a significant relation was found between the presence of pressure ulcers and age ( P  ≤ 0.022), Braden score ( P  ≤ 0.01) and bowel incontinence ( P  ≤ 0.01).
Conclusion  It is crucial to select appropriate and applicable preventive material/devices and nursing care measures. Moreover, factors related to the presence of pressure ulcers should be taken into consideration in order to prevent development of further pressure ulcers.     

Physical capacities assessment in critically ill patients: An exploratory study

BackgroundThe severity of muscle weakness after critical illness is very heterogeneous. To identify those patients who may maximally benefit from early exercises would be highly valuable. This implies an assessment of physical capacities, comprised at least of strength measurement and functional tests.ObjectivesThe objective of this study was to investigate the relationship between muscle strength and functional tests in an intensive care unit (ICU) setting.MethodsAdults with ICU length of stay ≥2 days were included. Handgrip strength (HG) and maximal isometric quadriceps strength (QS) were assessed using standardised protocols as soon as patients were alert and able to obey commands. At the same time, their maximal level of mobilisation capabilities and their autonomy were assessed using ICU Mobility Scale (ICU-MS) and Barthel Index, respectively.ResultsNinety-three patients with a median age of 64 [57–71.5] years, body mass index of 26.4 [23.4–29.6] kg/m², and Simplified Acute Physiology Score II of 33 [27.7–41] were included. Absolute and relative QS were, respectively, 146.7 [108.5–196.6] N and 1.87 [1.43–2.51] N/kg. HG was 22 [16–31] kg. The ICU-MS score was 4 [1–5]. A significant positive correlation was observed between HG and absolute QS (r_s = 0.695, p < 0.001) and between HG and relative QS (r_s = 0.428, p < 0.001). The ICU-MS score correlated with HG, with a weak positive relationship (r_s = 0.215, p = 0.039), but not with QS. The ICU-MS score did not statistically differ between the weakest and strongest patients for absolute or relative QS, but was lower in patients with the lowest HG values (p = 0.01). A weak positive correlation was observed between the Barthel Index and muscle strengths (maximum r_s = 0.414, p < 0.001).ConclusionsThe present results suggest that, during ICU stay, there is no strong association between muscle strength and functional test such as the ICU-MS or Barthel Index. Muscle dynamometry and functional tests are probably complementary tools for physical capacities quantification.     

Long-term cognitive impairment and delirium in intensive care: A prospective cohort study

Background

Whilst there is a growing body of research exploring the effect of delirium in intensive care unit (ICU) patients, the relationship between patient delirium and long-term cognitive impairment has not been investigated in settings where low rates of delirium have been reported.

Barriers to rehabilitation after critical illness: a survey of multidisciplinary healthcare professionals caring for ICU survivors in an acute care hospital

BackgroundThere is scant literature on the barriers to rehabilitation for patients discharged from the intensive care unit (ICU) to acute care wards.ObjectivesThe objective of this study was to assess ward-based rehabilitation practices and barriers and assess knowledge and perceptions of ward clinicians regarding health concerns of ICU survivors.Methods, design, setting, and participantsThis was a single-centre survey of multidisciplinary healthcare professionals caring for ICU survivors in an Australian tertiary teaching hospital.Main outcome measuresThe main outcome measures were knowledge of post–intensive care syndrome (PICS) amongst ward clinicians, perceptions of ongoing health concerns with current rehabilitation practices, and barriers to inpatient rehabilitation for ICU survivors.ResultsThe overall survey response rate was 35% (198/573 potential staff). Most respondents (66%, 126/190) were unfamiliar with the term PICS. A majority of the respondents perceived new-onset physical weakness, sleep disturbances, and delirium as common health concerns amongst ICU survivors on acute care wards. There were multifaceted barriers to patient mobilisation, with inadequate multidisciplinary staffing, lack of medical order for mobilisation, and inadequate physical space near the bed as common institutional barriers and patient frailty and cardiovascular instability as the commonly perceived patient-related barriers. A majority of the surveyed ward clinicians (66%, 115/173) would value education on health concerns of ICU survivors to provide better patient care.ConclusionThere are multiple potentially modifiable barriers to the ongoing rehabilitation of ICU survivors in an acute care hospital. Addressing these barriers may have benefits for the ongoing care of ICU survivors.     

Device-related pressure injuries in adult intensive care unit patients: An Australian and New Zealand point prevalence study

BackgroundDevice-related pressure injuries (DRPIs) are an ongoing iatrogenic problem evident in intensive care unit (ICU) settings. Critically ill patients are at high risk of developing pressure injuries caused by devices.ObjectiveThe aim of the study was to determine the prevalence of DRPI in critically ill patients in intensive care and the location, stage, and attributable device of DRPI and describe the products and processes of care used to prevent these injuries.MethodsThis was a prospective, multicentre, cross-sectional point prevalence study of patients aged more than 16 years in Australian and New Zealand ICUs. The study was part of the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program coordinated by The George Institute for Global Health.Main outcome measureIdentification of DRPI on the study day was the main outcome measure.ResultsOf the 624 patients included from 44 participating ICUs, 27 were found to have 35 identified DRPIs, giving a point prevalence DRPI rate of 4.3% (27/624). Study patients had a mean age of 59 years, and 60.3% were men. Patients with DRPI compared with patients without DRPI were significantly heavier (median: 92 kg versus 80 kg, respectively, p = 0.027), were less likely to survive the ICU (63.0% versus 85.9%, respectively, p = 0.015), had higher Acute Physiology and Chronic Health Evaluation II scores at admission to the ICU (median: 20 versus 16, respectively, p = 0.001), received mechanical ventilation more often (88.9% versus 43.5%, respectively, p < 0.001), and were more frequently diagnosed with respiratory conditions (37.0% versus 18.6%, respectively, p = 0.022). Processes of care activities were surveyed in 42 ICUs. Most DRPIs were attributed to endotracheal tubes and other respiratory devices. Forty-two ICUs reported processes of care to prevent DRPI, and just more than half of the participating sites (54.8%, 23/44) reported a dedicated ICU-based protocol for prevention of DRPI.ConclusionDRPIs pose a burden on patients in the ICU. Our study showed a DRPI prevalence comparable with other studies. Prevention strategies targeting DRPI should be included in ICU-specific pressure injury prevention guidelines or protocols.     

An exploratory study of patients' perceptions, memories and experiences of an intensive care unit

In the research reported, 298 patients were asked to describe their memories of the Royal Melbourne Hospital's intensive care unit (ICU). The data were collected by either self-reported questionnaires or structured interviews and examined from a bio-psycho-social perspective using both qualitative and quantitative methods. These recollections demonstrate that the close surveillance by both technological support and health care practitioners provide many patients and their families with a feeling of safety. Patients' memories of ICU also highlighted the presence of power relations which are inherent in clinical practice. This paper provides examples of actions and remarks within ICU that were not only remembered by patients and their families but also continued to effect patients 6 months after their discharge. The data in this research indicate that some of the psychological problems experienced after discharge may have been prevented by improved communication between staff and patients in ICU. This study also demonstrated the importance of providing feedback to the nurses working in ICU. This feedback raised awareness of patients' perceptions of both ICU itself and the behaviour of the staff. It also reminded staff that some patients remember everything about their admission of ICU. The data indicate that while patients found the presence of good communication in ICU both therapeutic and reassuring, they found the lack of good communication distressing. Poor communication not only caused anxiety while the patient was in ICU but also contributed to less than optimal recoveries after discharge. Finally, it will be argued that the provision of information from nurses not only diminished feelings of anxiety but also empowered patients to become involved in decisions about their care.     

Post-traumatic stress disorder-related symptoms in relatives of patients following intensive care

Objective To evaluate the effectiveness of the provision of information in the form of a rehabilitation program following critical illness in reducing psychological distress in the patients close family.Design Randomised controlled trial, blind at follow-up with final assessment at 6 months.Setting Two district general hospitals and one teaching hospital.Patients and participants The closest family member of 104 recovering intensive care unit (ICU) patients.Interventions Ward visits, ICU clinic appointments at 2 and 6 months. Relatives and patients received the rehabilitation program at 1 week after ICU discharge. The program comprised a 6-week self-help manual containing information about recovery from ICU, psychological information and practical advice.Measurements and results Psychological recovery of relatives was assessed by examining the rate of depression, anxiety, and post-traumatic stress disorder (PTSD)-related symptoms by 6 months after ICU. The proportion of relatives scoring in the range >19 on the Impact of Events Scale (cause for concern) was high in both groups at 49% at 6 months. No difference was shown in the rate of depression, anxiety, or PTSD-related symptoms between the study groups.Conclusion A high incidence of psychological distress was evident in relatives. Written information concerning recovery from ICU provided to the patient and their close family did not reduce this. High levels of psychological distress in patients were found to be correlated with high levels in relatives.