A family intervention to reduce delirium in hospitalised ICU patients: A feasibility randomised controlled trial

BackgroundFamily members could play an important role in preventing and reducing the development of delirium in Intensive Care Units (ICU) patients. This study sought to assess the feasibility of design and recruitment, and acceptability for family members and nurses of a family delivered intervention to reduce delirium in ICU patients.MethodA single centre randomised controlled trial in an Australian medical/surgical ICU was conducted. Sixty-one family members were randomised (29 in intervention and 32 in non-intervention group). Following instructions, the intervention comprised the family members providing orientation or memory clues (family photographs, orientation to surroundings) to their relative each day. In addition, family members conducted sensory checks (vision and hearing with glasses and hearing aids); and therapeutic or cognitive stimulation (discussing family life, reminiscing) daily. Eleven ICU nurses were interviewed to gain insight into the feasibility and acceptability of implementing the intervention from their perspective.ResultsRecruitment rate was 28% of eligible patients (recruited n = 90, attrition n = 1). Following instruction by the research nurse the family member delivered the intervention which was assessed to be feasible and acceptable by family members and nurses. Protocol adherence could be improved with alternative data collection methods. Nurses considered the activities acceptable.ConclusionThe study was able to recruit, randomise and retain family member participants. Further strategies are required to assess intervention fidelity and improve data collection.     

Feasibility and safety of in-bed cycling for physical rehabilitation in the intensive care unit

PurposeThe purpose was to evaluate the feasibility and safety of in-bed cycle ergometry as part of routine intensive care unit (ICU) physical therapist (PT) practice.Materials and methodsBetween July 1, 2010, and December 31, 2011, we prospectively identified all patients admitted to a 16-bed medical ICU receiving cycling by a PT, prospectively collected data on 12 different potential safety events, and retrospectively conducted a chart review to obtain specific details of each cycling session.ResultsSix hundred eighty-eight patients received PT interventions, and 181 (26%) received a total of 541 cycling sessions (median [interquartile range {IQR}] cycling sessions per patient, 2 [1-4]). Patients’ mean (SD) age was 57 (17) years, and 103 (57%) were male. The median (IQR) time from medical ICU admission to first PT intervention and first cycling session was 2 (1-4) and 4 (2-6) days, respectively, with a median (IQR) cycling session duration of 25 (18-30) minutes. On cycling days, the proportion of patients receiving mechanical ventilation, vasopressor infusions, and continuous renal replacement therapy was 80%, 8%, and 7%, respectively. A single safety event occurred, yielding a 0.2% event rate (95% upper confidence limit, 1.0%).ConclusionsUse of in-bed cycling as part of routine PT interventions in ICU patients is feasible and appears safe. Further study of the potential benefits of early in-bed cycling is needed.     

A 6-y retrospective cohort study of family satisfaction with critical care and decision-making in an Australian intensive care unit

BackgroundPartnering with patients and families to make decisions about care needs is a safety and quality standard in Australian health services that is often not assessed systematically.ObjectiveThe objective of this study was to retrospectively evaluate satisfaction with care and involvement in decision-making among family members of patients admitted to the intensive care unit (ICU).MethodsA retrospective cohort analysis of a satisfaction survey administered to family members of patients admitted to an ICU in an Australian metropolitan tertiary care hospital from 2014 to 2019 was conducted. The Family Satisfaction in the Intensive Care Unit questionnaire (FSICU) questionnaire was used to assess overall satisfaction, satisfaction with care, and satisfaction with decision-making on a scale from “poor” (0) to “excellent” (100).ResultsIn total, 1322 family members fully completed the survey. Respondents were typically direct relatives of ICU patients (94.2%) with an average age of 52.6 years. Most patients had an ICU length of stay <7 d (56.8%), with most patients being discharged to the ward (96.8%). The overall mean satisfaction score was high among respondents (90.26%). Similarly, mean satisfaction with care (93.06%) and decision-making (89.71%) scores were high. Satisfaction with decision-making scores remained lower than satisfaction with care scores. Multivariable modeling indicated that those younger than 50 years reported higher satisfaction scores (p = 0.006) and those with prolonged lengths of stay in the ICU were associated with lower overall satisfaction scores (p = 0.039). Despite some criticism of waiting times and noise levels, responses showed sincere gratitude for patients’ treatment in the ICU and appreciation for the care, skill, and professionalism of the staff.ConclusionVery high satisfaction levels were reported by family members during this study. Routine, prospective evaluations of family member satisfaction with ICU experiences are feasible and can be leveraged to provide insight for clinicians and administrators seeking to improve family satisfaction with decision-making and care in ICU settings and meet national standards.     

Effect of in-bed cycling on acute muscle wasting in critically ill adults: A randomised clinical trial

PurposeTo examine whether in-bed cycling assists critically ill adults to reduce acute muscle wasting, improve function and improve quality of life following a period of critical illness.Materials and methodsA single-centre, two-group, randomised controlled trial with blinded assessment of the primary outcome was conducted in a tertiary ICU. Critically ill patients expected to be mechanically ventilated for at least 48 h were randomised to 30 min daily in-bed cycling in addition to usual-care physiotherapy (n = 37) or usual-care physiotherapy (n = 37). The primary outcome was muscle atrophy of rectus femoris cross-sectional area (RF_CSA) measured by ultrasound at Day 10 following study enrolment. Secondary outcomes included manual muscle strength, handgrip strength, ICU mobility score, six-minute walk test distance and health-related quality of life up to six-months following hospital admission.ResultsAnalysis included the 72 participants (mean age, 56-years; male, 68%) who completed the study. There were no significant between-group differences in muscle atrophy of RF_CSA at Day 10 (mean difference 3.4, 95% CI -6.9% to 13.6%; p = .52), or for secondary outcomes (p-values ranged p = .11 to p = .95).Conclusions and relevanceIn-bed cycling did not reduce muscle wasting in critically ill adults, but this study provides useful effect estimates for large-scale clinical trials.Trial registrationanzctr.org.au Identifier: ACTRN12616000948493.     

Feasibility of Using Communication Coaching to Teach Palliative Care Clinicians Motivational Interviewing

ContextPalliative care clinicians often have challenging conversations with patients or family caregivers who express ambivalence about goals or feel reluctant to discuss topics. Motivational Interviewing (MI) has tools to address ambivalence and reluctance.ObjectiveThe aim of this pilot study was to test the feasibility, acceptability, and preliminary efficacy of an MI communication coaching intervention.MethodsWe enrolled 22 palliative care clinicians and randomly assigned half to receive communication coaching versus wait-list control. The coaching entailed a lecture on MI, a 1:1 session to discuss applying MI, and audio recording and receiving feedback on four encounters (two separate times). Palliative care clinicians in the wait-list control arm audio-recorded four encounters. Coders blinded to study arm coded MI behaviors. We surveyed patients, caregivers, and clinicians after all audio-recorded encounters to assess perceptions of the encounter. The analyses were performed using a repeated-measures mixed model.ResultsWe found the intervention to be feasible and acceptable. Eighty-six percent of those enrolled completed all study activities including coaching sessions, audio-recording encounters, and completing surveys. Of those in the intervention arm, 88% rated the intervention as helpful and 100% would recommend it to a colleague. Compared to control clinicians, intervention clinicians had higher ratings of their MI skills after intervention, higher objectively rated communication skills, and slightly better burnout scores. We found no arm differences in patient, caregiver, or clinician ratings of satisfaction.ConclusionThis pilot study indicates that coaching palliative care clinicians is feasible and shows promise that coaching can improve palliative care clinician communication.     

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.     

Coping Skills Training and Acceptance and Commitment Therapy for Symptom Management: Feasibility and Acceptability of a Brief Telephone-Delivered Protocol for Patients With Advanced Cancer

ContextPatients with advanced cancer face a life-limiting condition that brings a high symptom burden that often includes pain, fatigue, and psychological distress. Psychosocial interventions have promise for managing symptoms but need additional tailoring for these patients' specific needs. Patients with advanced cancer in the community also face persistent barriers—availability of interventions in community clinics as well as financial and illness-related factors—to accessing psychosocial interventions.ObjectivesThe aim of the present study was to assess the feasibility and acceptability of telephone implementation of Engage, a novel brief combined Coping Skills Training and Acceptance and Commitment Therapy protocol, for reducing symptoms and increasing quality of life in community patients with advanced cancer.MethodsAdult patients with advanced cancer receiving care in the community received Engage, four 60-minute manualized telephone sessions delivered by a trained psychotherapist and completed pretreatment and post-treatment assessments.ResultsEngage was feasible, achieving 100% accrual (N = 24) of a heterogeneous sample of patients with advanced cancer, with good retention (88% completed). Acceptability was demonstrated via satisfaction (mean 29 of 32; SD 2), engagement (95% attendance), and use of skills. Secondary analyses pointed to reductions in pain interference, fatigue, psychological distress, and improvements in psychological acceptance and engagement in value-guided activity after treatment.ConclusionEngage, our brief novel combined Coping Skills and Acceptance and Commitment Therapy intervention, demonstrated initial feasibility and acceptability when delivered over the telephone and increased access for community clinic patients with advanced cancer. Future research will assess the comparative efficacy of Engage in larger randomized trials.     

卧式脚踏车运动在预防患者血液透析中低血压的应用研究

目的 观察卧式脚踏车运动对降低患者血液透析中低血压发生率的影响.方法 选取97例维持性血液透析患者作为研究对象,采用随机数字表分为对照组49例及观察组48例,对照组给予常规维持性血液透析护理,观察组在此基础上进行透析中卧式脚踏车运动.比较两组患者干预前3个月及干预3个月期间透析中低血压的发生率,干预3个月后好转率.结果...     

The Acceptability and Feasibility of Using Mortality Prediction Scores for Initiating End-of-Life Goals-of-Care Communication in the Adult Intensive Care Unit

ContextUncertainties in prognosis remain a barrier to end-of-life (EOL) communication in the intensive care unit (ICU), thus strategies are needed for increasing the precision of prognosis and timeliness of EOL goals-of-care communication. Use of mortality prediction scores offers one approach to this issue.ObjectivesThis study evaluated the acceptability and feasibility of providers' use of patient mortality prediction scores as part of routine practice to increase prognosis precision and timeliness of EOL communication as well as providers' intentions to change practice related to EOL goals-of-care communication based on awareness of the scores.MethodsAn explanatory mixed-methods approach was used to provide Sequential Organ Failure Assessment (SOFA) patient mortality prediction scores to ICU providers, who then completed an acceptability and feasibility questionnaire and participated in follow-up interviews conducted to further understand questionnaire responses and gain insight into their perceptions based on having SOFA scores.ResultsProviders reported that using SOFA scores was acceptable and feasible, although there was some disagreement about effectiveness of SOFA scores for determining mortality risk. Providers with limited ICU experience were eager, and accepting of the scores while those with more experience found the scores to be an adjunct to their own intuition, although all acknowledged the benefit of looking at score trends. An important finding was the need to consider SOFA scores in relation to patient clinical context.ConclusionUse of SOFA scores as a means to potentially increase EOL goals-of-care communication emerged as most beneficial and acceptable to providers with limited ICU experience.     

Risk factors for prolonged intensive care unit stays in patients after cardiac surgery with cardiopulmonary bypass: A retrospective observational study

ObjectivesPatients after cardiac surgery with cardiopulmonary bypass (CPB) require a stay in the ICU postoperatively. This study aimed to investigate the incidence of prolonged length of stay (LOS) in the ICU after cardiac surgery with CPB and identify associated risk factors.MethodsThe current investigation was an observational, retrospective study that included 395 ICU patients who underwent cardiac surgery with CPB at a tertiary hospital in Guangzhou from June 2015 to June 2017. Data were obtained from the hospital database. Binary logistic regression modeling was used to analyze risk factors for prolonged ICU LOS.ResultsOf 395 patients, 137 (34.7%) had a prolonged ICU LOS (>72.0 h), and the median ICU LOS was 50.9 h. Several variables were found associated with prolonged ICU LOS: duration of CPB, prolonged mechanical ventilation and non-invasive assisted ventilation use, PaO₂/FiO₂ ratios within 6 h after surgery, type of surgery, red blood cell infusion during surgery, postoperative atrial arrhythmia, postoperative ventricular arrhythmia (all P < 0.05).ConclusionsThese findings are clinically relevant for identifying patients with an estimated prolonged ICU LOS, enabling clinicians to facilitate earlier intervention to reduce the risk and prevent resulting delayed recovery.     

Feasibility and acceptability of a self-managed exercise to rhythmic music intervention for ICU survivors

BackgroundPost-ICU rehabilitation is a challenging clinical issue for patients discharged from an Intensive Care Unit (“ICU survivors”). Our exercise to rhythmic music intervention was designed to allow ICU survivors to self-manage their exercise by following a personalized, recorded exercise playlist.AimOur study reports the feasibility and acceptability of an innovative music intervention among ICU survivors enrolled in a randomized controlled pilot study.MethodsICU survivors, admitted in ICU for at least 5 days and cognitively intact, were randomly assigned to an exercise to rhythmic music group (n = 10) or an active control group (n = 10). Participants in the music group were taught to self-manage exercise by listening to a recorded playlist of instructions and music-facilitated movements tailored to their musical preference and exercise ability. Participants in the control group were provided a brochure with exercise instructions. After 5 days or at hospital discharge, participants completed an 8-item acceptability questionnaire and were interviewed. Content analysis was conducted.Results18 Participants were included for final analysis. Participants were 61.8 ± 14.7 years old, predominantly male (66.7%), and Caucasian (55.6%). Results demonstrated feasibility, as the study team was able to meet the enrollment goal of 5–6 participants per month. Three themes related to general, physical, and psychosocial benefits were identified. Based on positive feedback, the exercise to rhythmic music intervention was deemed acceptable.ConclusionThe exercise to rhythmic music intervention was feasible and acceptable, suggesting that clinical trials with larger sample sizes should investigate the effects of the intervention on outcomes among ICU survivors.     

Feasibility of using the “modified NUTrition Risk In the Critically ill” nutritional risk screening tool to identify nutritionally at-risk patients in an Australian intensive care unit

BackgroundThe modified NUTrition Risk In the Critically ill (mNUTRIC) score has been demonstrated to accurately quantify the risk of negative patient outcomes and discriminate which patients will benefit the most from nutrition intervention in an intensive care unit (ICU) setting. Calculation of an mNUTRIC score, however, may be time-intensive and unable to be performed within available resources. This may prevent high-risk patients from being identified and reviewed by a dietitian.ObjectivesThe purpose of this study was to assess the feasibility of using the mNUTRIC tool to screen for patients at increased nutrition risk and to determine the proportion of those high-risk patients who were reviewed by a dietitian.Subjects/methodsA retrospective observational study of 260 critically ill patients was conducted between 01/01/2017 and 30/05/2017 in a 20-bed Australian tertiary ICU. Participants included all adults admitted to the ICU for more than 72 h. Feasible implementation was defined as calculating an mNUTRIC score in <5 min per patient where all data were available for >90% of patients.ResultsA median time of 4 min and 54 s (interquartile range: 4.3–5.6 min) was required to calculate each mNUTRIC score, with 96% of scores calculated in <10 min. Data were available to calculate mNUTRIC scores for 93% (241/260) of patients. The mNUTRIC tool identified 81 patients at high nutrition risk, 44% (36/81) of whom were not reviewed by a dietitian. There were 21 high-risk patients who were purposefully excluded from dietetic review for various clinical reasons, leaving 15 high-risk patients (19%) who were not reviewed by a dietitian.ConclusionsImplementation of the mNUTRIC tool was not feasible in our ICU, given the set dietetic resources (0.6 full-time equivalent). Shared responsibility of nutrition screening or automating the calculation may be possible solutions to increase feasibility of mNUTRIC screening.     

Facilitating the relocation of an intensive care unit from shared room to single room setting: Staff perceptions on the effectiveness of a multicomponent intervention

BackgroundCurrent strategies for new and redesigned intensive care units (ICUs) involve incorporation of single occupancy rooms. These changes have largely been made for infection control and patient privacy reasons. However, there is limited literature available on how to manage the transition of an ICU from shared room to a single room environment.AimsThe aim of this study was to evaluate staff members' perceived effectiveness of a multicomponent intervention to facilitate transition from a shared to a single room setting.MethodsThis qualitative study was conducted in a 20-bed ICU of an Australian tertiary teaching hospital. In total, 24 staff members were interviewed in five groups and five individual interviews 6 months after the ICU relocation.FindingsThree themes emerged from data analysis: (1) facilitating staff members' transition and engagement during relocation planning; (2) simulating new work processes for the single room setting; and (3) supporting nurses working in the single rooms. The components of the intervention, including the change agent, the relocation working party, Assistance, Coordination, Contingency, Education, Supervision, and Support nurse rounding model, and the safe single room model, were perceived as important strategies to support the relocation transition. The regular newsletter and the information dissemination strategy informed by the social networking survey were viewed to improve communication. Staffing levels and education models that are suitable for the single room setting were identified as areas for improvement.Discussion and ConclusionA systematic change management approach, clear communication, staff engagement, and continuously monitoring new work processes are important strategies to ensure the success of the relocation. Delivery of education in the clinical area needs to be further explored to ascertain the impact of a single room environment on its delivery. Intervention co-creation involving research team members and the clinical staff was important in building change management capacity, which may contribute to intervention sustainability and continued clinical practice improvement.     

Staff experiences,perceptions of care,and communication in the intensive care unit during the COVID-19 pandemic in Australia

BackgroundIn 2020, during the first wave of the COVID-19 pandemic in Australia, hospital intensive care units (ICUs) revised patient care practices, curtailed visiting, and augmented the use of personal protective equipment to protect patients, staff, and the community from viral transmission.AimThe aim was to explore ICU staff experiences and perceptions of care and communication with patients during the COVID-19 pandemic to understand how alternative ways of working have influenced work processes, relationships, and staff morale.MethodsThis was a qualitative exploratory design study using audio-recorded and transcribed interviews with 20 ICU staff members. Data were analysed using thematic analysis.FindingsFour major themes were derived from the data: (i) Communication and connection, (ii) Psychological casualties, (iii) Caring for our patients, and (iv) Overcoming challenges. Patient care was affected by diminished numbers of critical care qualified staff, limited staff entry to isolation rooms, and needing to use alternative techniques for some practices. The importance of effective communication from the organisation and between clinicians, families, and staff members was emphasised. personal protective equipment hindered communication between patients and staff and inhibited nonverbal and verbal cues conveying empathy in therapeutic interactions. Communication with families by phone or videoconference was less satisfying than in-person encounters. Some staff members suffered psychological distress, especially those working with COVID-19 patients requiring extracorporeal membrane oxygenation. Moral injury occurred when staff members were required to deny family access to patients. Workload intensified with increased patient admissions, additional infection control requirements, and the need to communicate with families using alternative methods.ConclusionThe results of this study reflect the difficulties in communication during the early stages of the COVID-19 pandemic. Communication between staff members and families may be improved using a more structured approach. Staff reported experiencing psychological stress when separating families and patients or working in isolation rooms for prolonged periods. A flexible, compassionate response to family presence in the ICU is essential to maintain patient- and family-centred care.     

Evaluation of a mindfulness and self-compassion-based psychotherapy incorporating horses for Veterans who have experienced trauma

ObjectivesThe primary aim of this pilot study was to assess the safety, feasibility, acceptability, as well as preliminary outcomes of a mindfulness and self-compassion-based psychotherapy incorporating horses (PIH) intervention, Whispers with Horses, for Veterans who had experienced trauma. Whispers with Horses was developed as a structured intervention that could be easily replicated for additional studies. If shown to be effective by future rigorous research, the aim is to disseminate a manualized version of the intervention to the field.DesignProspective open trial.SettingA large Veterans Administration healthcare system and local equine facilities.InterventionA six-session PIH intervention that focused on participants developing or enhancing mindfulness and self-compassion skills in the context of an emerging horse-human relationship.Main outcome measuresSafety, feasibility and acceptability were assessed, and psychological instruments were administered. Instruments utilized were the PTSD Checklist for DSM 5 (PCL-V), the Patient Health Questionnaire 9 (PHQ-9), the Positive and Negative Affect Scale (PANAS), the Acceptance and Action Questionnaire II (AAQ-II), and the Physical Activity Enjoyment Scale (PACES).ResultsSubjects were 33 Veterans who were 52% male with a mean age of 46 years-old. There were no adverse outcomes to participants indicating the intervention was safe. Participants completed an average of 3.8 sessions with 24% completing all sessions indicating the intervention is feasible to use, and acceptable to, the population studied. The mean PACES score for all sessions together was 110.4, indicating subjects generally enjoyed participation. Preliminary outcome assessments revealed pre- to post-session significant improvements in affect and psychological flexibility for some sessions (p ranging from.001 −0.015). Pre- to post-intervention outcomes indicated significant improvements in depression (p = .003) and psychological flexibility (p = .005).ConclusionsThe Whispers with Horses intervention shows promise as a PIH for Veterans who have experienced trauma. More rigorous studies of this intervention are warranted. Also, additional investigations aimed at better understanding mechanisms underlying changes in psychological flexibility are justified.