Long-term follow-up of ICU patients.

Critical care medicine programs must provide outpatient experience for their fellowship trainees. We have developed an unusual follow-up plan allowing critical care fellows to contact their patients months after their intensive care unit stay. We evaluated responses of 46 patients after a mean interval of 8.6 months since their initial intensive care unit stay. Patients were stratified by severity of disease by using the APACHE scoring system. Diagnostically, the patients represented the typical medical-surgical intensive care unit population. Patients were asked 11 questions concerning their health and socio-emotional status as it related to their hospitalization and intensive care unit stay. Our results established a practical method of providing outpatient follow-up that may fulfill residency review requirements for critical care fellowships, confirmed previously speculative ideas about ICU experiences, and suggested future research opportunities to study intensive care unit patients following discharge.     

Visiting preferences of patients in the intensive care unit and in a complex care medical unit.

BACKGROUND: Within the challenging healthcare environment are nurses, patients, and patients' families. Families want proximity to their loved ones, but the benefits of such proximity depend on patients' conditions and family-patient dynamics. OBJECTIVES: To describe patients' preferences for family visiting in an intensive care unit and a complex care medical unit. METHODS: Sixty-two patients participated in a structured interview that assessed patients' preferences for visiting, stressors and benefits of visiting, and patients' perceived satisfaction with hospital guidelines for visiting. RESULTS: Patients in both units rated visiting as a nonstressful experience because visitors offered moderate levels of reassurance, comfort, and calming. Patients in the intensive care unit worried more about their families than did patients in the complex care medical unit but valued the fact that visitors could interpret information for the patients while providing information to assist the nurse in understanding the patients. Patients in the intensive care unit were more satisfied with visiting practices than were patients in the complex care medical unit, although both groups preferred visits of 35 to 55 minutes, 3 to 4 times a day, and with usually no more than 3 visitors. CONCLUSIONS: These data provide the input of patients in the ongoing discussion of visiting practices in both intensive care units and complex care medical units. Patients were very satisfied with a visiting guideline that is flexible enough to meet their needs and those of their family members.     

重症加强治疗病房清醒患者不良住院经历调查分析

目的 调查重症加强治疗病房(ICU)清醒危重患者住院期间心理及生理不良经历的发生情况,并分析相关诱发因素.方法 选择全国31家三级甲等医院ICU进行为期2个月的连续性调查,所有转出ICU的清醒患者均入选本次调查,于转出后2 d内由上海诺德健康咨询有限公司委派、经课题组系统培训合格的访问员按问卷要求独立对患者进行访问.结果 共计234例患者接受调查,其中163例(69.6%)发生了心理不良经历;有生理不良经历患者的比例高达97.0%,其中74.8%的患者发生了严重生理不良经历.有86.5%存在心理不良经历的患者发生了严重生理不良经历,显著高于无心理不良经历的患者(46.5%),差异有统计学意义(P<0.01).分别有65.8%和74.8%的患者抱怨对噪音及医护操作难以忍受,且此类患者心理及生理不良经历的比例均较能耐受者显著增高(P<0.05或P<0.01).多因素分析发现,急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分为诱发心理不良经历的独立高危因素[优势比(OR)=1.070,95%可信区间(CI)为1.020～1.130,P<0.05];年龄因素为发生生理不良经历的高危因素(OR=0.936,95%CI为0.879～0.998,P<0.05).此外,恰当的镇静能有效降低ICU清醒危重患者心理及生理不良经历的发生率.结论 ICU清醒危重患者不良住院经历发生率高,存在心理不良经历的患者更容易出现生理不良经历.疾病严重程度是诱发不良心理经历的独立危险因素,ICU环境因素(如噪音)以及医护操作与心理及生理不良经历关系密切,而恰当的ICU镇静策略是减少心理及生理不良经历的有效措施之一.     

Staff empowerment in Finnish intensive care units

The purpose of this study was to describe staff empowerment in Finnish intensive care units. The data were collected with a questionnaire comprising demographic background and empowerment items. The concept of empowerment was divided into three components: behavioural, verbal and outcome empowerment. The questionnaire was sent to all registered nurses at Finnish intensive care units (ICUs). Eight hundred and fourteen replied, giving a response rate of 77%. The ICU nurses demonstrated confidence in their own skills and competencies, although least so in the domain of outcome empowerment. Experience of behavioural, verbal and outcome empowerment increased linearly with age. The length of nursing experience was positively associated with behavioural, verbal and outcome empowerment. Experience in ICU nursing correlated positively with verbal and outcome empowerment. Motivation, job satisfaction, respect of job autonomy and the fact that the job of ICU nurses commanded respect in society were associated with behavioural, verbal, and outcome empowerment.     

对我国首次载人航天航天员医疗保障及救护措施的探讨

目的：探讨首次载人航天航天员的医疗保障及救护体会。方法：结合我们已进行的医疗救护演练和首次载人航天航天员的医疗保障及救护体会，回顾与分析国内外有关载人航天航天员已经发生的意外伤害资料并分析其原因，提出有效的防治措施。结果：主要针对载人航天航天员发生意外伤害的原因，把一个高质量的加强医疗病房(ICU)全天候移至草原和沙漠上，可以确保意外情况下航天员的安全。制订医疗保障措施，使救护方案更趋于合理，并保证反应速度和技术装备的先进性。结论：对返回着陆场区的航天员实施紧急医疗保障及救护是保障航天员安全及圆满完成载人航天任务的一个必不可少的重要环节。     

Demographic and clinical determinants of having do not resuscitate orders in the intensive care unit of a comprehensive cancer center

To understand the needs of patients and family members as physicians communicate their expectations about patients admitted to the intensive care unit (ICU), we evaluated the demographic and clinical determinants of having a Do Not Resuscitate (DNR) order for adults with cancer. Patients included were admitted from June 16, 2008-August 16, 2008, to the ICU in a comprehensive cancer center. We conducted a prospective chart review and collected data on patient demographics, length of stay, advance directives, clinical characteristics, and DNR orders. A total of 362 patients met the inclusion criteria; only 15.2% had DNR orders before ICU discharge. In the multivariate analysis, we found that medical admission was an independent predictor of having a DNR order during the ICU stay (odds ratio = 3.65; 95% confidence interval, 1.44-9.28); we also found a significant two-way interaction between race/ethnicity and type of admission (medical vs. surgical) with having a DNR order (p =?.04). Although medical admissions were associated with significantly more DNR orders than were surgical admissions, we observed that the subgroup of non-white patients admitted for medical reasons was significantly less likely to have DNR orders. This finding could reflect different preferences for aggressive care by race/ethnicity in patients with cancer, and deserves further investigation.     

Good nursing care to ICU patients on the edge of life

Critically ill patients are admitted to intensive care units (ICUs) to receive advanced technological and medical treatment. Some patients seem not to benefit from the treatment, and sometimes questions are raised as to whether treatment should be withheld or withdrawn. This study was conducted using ICU nurses' experiences with the aim of acquiring a deepened understanding of what good nursing care is for these patients. The study was performed at an adult ICU in Norway, where 14 ICU female nurses were included as participants. The research design was based on interpretative phenomenology and data was collected by group interviews inspired by focus-group methodology. The participants were divided into two groups and each group was interviewed four times. Colaizzi's model was used in the process of analysis. The results show that good nursing care depended on several basic conditions: continuity, knowledge, competence and cooperation, and included clear goals to give appropriate life-saving -- or end-of-life treatment and care. Cornerstones in good nursing care were nurses' verbal communication and nurses' use of their hands. The study emphasises several consequences for future ICU nursing practice and education to enhance good nursing care to patients on the edge of life.     

Ambulatory care-sensitive conditions: clinical outcomes and impact on intensive care unit resource use

BACKGROUND: We identified risk factors and clinical outcomes associated with ambulatory care-sensitive conditions requiring intensive care unit (ICU) admission. METHODS: This prospective cohort study included 4,144 patients admitted to the medical ICU of an urban teaching hospital during a 3-year period. RESULTS: A total of 627 patients were classified as having ambulatory care-sensitive conditions (ie, potentially preventable ICU admissions). Black race, decreasing Acute Physiology and Chronic Health Evaluation II (APACHE II) score, younger age, female sex, and absence of immunodeficiency were independently associated with ambulatory care-sensitive conditions. Patients classified as having ambulatory care-sensitive conditions accounted for 2,006 ventilator days, 2,508 ICU days, and 5,392 hospital days. The hospital mortality rate was statistically lower for patients with ambulatory care-sensitive conditions than for patients without these conditions. Patients classified as having ambulatory care-sensitive conditions were also statistically more likely than other patients to lack health insurance and to sign out of the hospital against medical advice. CONCLUSION: Patients with ambulatory care-sensitive conditions account for a substantial portion of all admissions to the intensive care unit. These data suggest that interventions aimed at preventing such admissions could improve ICU bed use.     

Steering a course towards advanced nurse practitioner: a critical care perspective

Aim: This article is a report of a study of the experiences of expert critical care nurses in their transition to the role of advanced nurse practitioner within an intensive care unit (ICU) setting. Background: The advanced nurse practitioner role was developed to support the ICU team and to undertake many of the roles traditionally associated with junior medical staff in this specialized area. The impetus for this study therefore was generated from the need to explore the role development experiences of trainee advanced nurse practitioners to inform future developments and practice. Methods: This study used grounded theory methodology to conduct and analyse data from 25 participants. The data were collected between March 2010 and August 2010, using interview format. Data collection and analysis was conducted simultaneously using methods associated with grounded theory, theoretical sampling and the constant comparative method. Results: ‘Staying the course to advanced nursing practice’ emerged as the core category, with four related major categories and substantive codes. In conjunction, the substantive theory explaining the essential processes involved comprised of three inextricably linked processes: situational, development and conceptual meaning. The developed conceptual model captures the unique experiences of expert critical care nurses during their transition to confident and competent advanced nurse practitioners. Conclusion: This study provides an account of the role transition from expert critical care nurse to advanced nurse practitioner, specifically the synthesis of expert nursing practice with traditional medical values. The conceptual model has the potential to be utilized as a framework for others embarking upon similar projects, informing advanced nurse practitioner roles within and out with critical care settings.     

Association between heart rate variability recorded on postoperative day 1 and length of stay in abdominal aortic surgery patients

OBJECTIVE: To determine whether heart rate variability (HRV) measured in the surgical intensive care unit (ICU) on the first postoperative day predicts clinical outcome in patients undergoing abdominal aortic surgery. DESIGN: Prospective study. SETTING: Eighteen-bed surgical ICU of a 1,442-bed university hospital. PATIENTS: One hundred and six patients admitted to the ICU after abdominal aortic surgery. MEASUREMENTS AND MAIN RESULTS: Twenty-four-hour Holter recordings were analyzed for standard time and frequency domain indices and one nonlinear index (slope) of HRV. Clinical and demographic data were collected from medical records. Patients were dichotomized into short (< or = 7 days) and long (> 7 days) length of stay (LOS) by median split. Patients with long LOS had increased heart rates and decreased short- and intermediate-term HRV but no difference in overall HRV, which primarily reflects circadian rhythm. Independent predictors of LOS were increased age, insulin-dependent diabetes, and decreased HRV. CONCLUSIONS: Increased heart rates and decreased intermediate-term HRV indices measured on postoperative day 1 were independent predictors of complicated recovery. The strongest HRV predictors of outcome were natural logarithm very-low-frequency power measured over 24 hrs and during the daytime. Results support the potential use of HRV for the prediction of postsurgical resource utilization.     

Beyond the walls: a review of ICU clinics and their impact on patient outcomes after leaving hospital.

INTRODUCTION: Patients often experience physical disability, neurocognitive and/or psychological impairment after surviving ICU. The burden arising from critical illness on patients, their families and health services may be substantial. Follow-up of these patients is important and ICU clinics have been introduced for this purpose. AIM: The aim of this review was to consider current research and reports from the literature about ICU follow-up clinics and their impact on patient outcomes for those who survived hospital after suffering critical illness. METHOD: The literature review included searches of the MEDLINE, EMBASE, and CINAHL databases. Studies were included if they described the setting up and conduct of the ICU follow-up clinic that required a visit to the clinic. RESULTS: Seven studies met the inclusion criteria, six of which were from the UK. The ICU follow-up clinics were predominantly nurse-led. There was no consensus on patient selection criteria for clinic attendance or method of follow-up. Clinic services were most often offered to patients who stayed in ICU three or more days. Attendance rates varied and were not reported for three studies. Attendance appeared to be influenced by the severity of illness. Cancellation and non-attendance rates were high for those studies reporting these data. Patients who did not live within the vicinity of the hospital were often excluded. Information about the sequelae of critical illness was provided and attendees were happy to discuss their experiences at the clinic. However, other important outcomes were not reported. CONCLUSION: Appropriate follow-up for survivors of intensive care and their family is important. However, evidence is limited on the benefit of ICU clinics for patients recovering from critical illness. Further research is needed to examine models that best meet patient needs after critical care.     

How do patients with exacerbated chronic obstructive pulmonary disease experience care in the intensive care unit?

The aim was to gain insight into how patients with advanced chronic obstructive pulmonary disease (COPD) experience care in the acute phase. The study has a qualitative design with a phenomenological approach. The empirics consist of qualitative in‐depth interviews with ten patients admitted to the intensive care units in two Norwegian hospitals. The interviews were carried out from November 2009 to June 2011. The data have been analysed through meaning condensation, in accordance with Amadeo Giorgi's four‐step method. Kari Martinsen's phenomenological philosophy of nursing has inspired the study. An essential structure of the patients' experiences of care in the intensive care unit by acute COPD‐exacerbation may be described as: Feelings of being trapped in a life‐threatening situation in which the care system assumes control over their lives. This experience is conditioned not only by the medical treatment, but also by the entire interaction with the caregivers. The essence of the phenomenon is presented through three themes which describe the patient's lived experience: preserving the breath of life, vulnerable interactions and opportunities for better health. Acute COPD‐exacerbation is a traumatic experience and the patients become particularly vulnerable when they depend on others for breathing support. The phenomenological analysis shows that the patients experience good care during breath of life preservation when the care is performed in a way that gives patients more insight into their illness and gives new opportunities for the future.     

Intensive care use in a developing country: a comparison between a Tunisian and a French unit

Objectives: To compare the variations in intensive care (ICU) outcome in relation to variations in resources utilization and costs between a developed and a developing country with different medical and economical conditions. Design and setting: Prospective comparison between a 26-bed French ICU and an 8-bed Tunisian ICU, both in university hospitals. Patients: Four hundred thirty and 534 consecutive admissions, respectively, in the French and Tunisian ICUs. Measurements: We prospectively recorded demographic, physiologic, and treatment information for all patients, and collected data on the two ICU structures and facilities. Costs and ICU outcome were compared in the overall population, in three groups of severity indexes and among selected diagnostic groups. Results: Tunisian patients were significantly younger, were in better health previously and were less severely ill at ICU admission (p < 0.01). French patients had a lower overall mortality rate (17.2 vs 22.5 %; p < 0.01) and received more treatment (p < 0.01). In the low severity range, the outcome and costs were similar in the two countries. In the highest severity range, Tunisian and French patients had similar mortality rates, while the former received less therapy throughout their ICU stays (p < 0.05). Conversely, in the mid-range of severity, mortality was higher among Tunisian patients, and a difference in management was identified in COPD patients. Conclusion: Although the Tunisian ICU might appear more cost-effective than the French one in the highest severity group of patients, most of this difference appeared in relation to shorter lengths of ICU stay, and a poorer efficiency and cost-effectiveness was suggested in the mid-range severity group. Differences in economical constraints may partly explain differences in ICU performances. These results indicate where resource allocation could be directed to improve the efficiency of ICU care. Received: 15 December 1997 Accepted: 8 July 1998     

A new conceptual framework for ICU performance appraisal and improvement

PURPOSE: This study examined the use of outcomes for the purposes of ICU evaluation and improvement. We reviewed the strengths and weaknesses of an outcomes-centered approach to intensive care unit (ICU) evaluation and present a more comprehensive conceptual framework for ICU evaluation and improvement. MATERIALS AND METHODS: Data was collected from 2 sources: (1) a structured review of the literature, with relevant articles identified using Medline, and (2) 85 semistructured interviews of health care professionals (eg, physicians) and health care administrators (eg, chief executive officer). The interviewees came from 4 institutions: a 900-bed East Coast teaching medical center, a 600-bed East Coast teaching medical center, a 590-bed East Coast teaching medical center, and a 435-bed West Coast private community hospital. A nonrandomized, purposeful sample was used. RESULTS: A conceptual framework for ICU evaluation is presented that identifies and defines 3 different types of variables: performance (eg, appropriateness of care, effectiveness of care), outcome (eg, resource use, mortality), and process (eg, timeliness of treatment, work environment).The framework emphasizes performance variables and the relationships between performance, outcome, and process of care variables, as a logical focus for ICU evaluation and improvement. CONCLUSIONS: Performance variables offer distinct advantages over outcome variables for ICU evaluation. Their use, however, will require additional development of current evaluation tools and methods. They provide the ability to identify the value an ICU adds to patient care in a hospital or to an episode of illness, and to evaluate integrated systems for providing care.     

Investigating the physiological responses of patients listening to music in the intensive care unit

Aims. To determine whether definable subtypes exist within a cohort of patients listening to music with regard to their physiological patterns and to compare whether associated factors vary between subjects in groups with different profiles. Background. The intensive care unit (ICU) is one of the most stressful environments for patients among various clinical settings in a hospital. ICU patients are not only compromised by illness but also faced with a wide range of stressors. Design. A repeated‐measures design was conducted with one music group. Method. One hundred and one patients were recruited in three intensive care units in Hong Kong. There were two main outcome variables: demographic characteristics and physiological outcomes. Results. A cluster analysis yielded two clusters. Patients in cluster 1 typically experienced relatively low therapeutic effects from listening to music. There were more males, of a younger age but more educated and employed than patients in cluster 2, and they represented 41·6% of the total respondents. Cluster 2 comprised almost 58·4% of this study sample and they reported high therapeutic effects of music. There were more females in this group as well as more older people and they mainly used a ventilator in the intensive care unit. Conclusion. Our study shows that music may have a more positive effect on groups of patients whose profile is similar to that of the patients in cluster 2, than for patients such as those in cluster 1. A clear profile may help health professionals to design appropriate care therapy to target a specific group of patients to improve their physiological outcomes. Relevance to clinical practice. The implication of this study is that music therapy should be provided to patients as a relaxation technique if they are willing to accept it, and the selection of music should be based on their preferences. Information should be given to patients so that they can understand how music therapy works and they should be encouraged to focus their attention on listening to the music to maximise its benefits.     

Predictive data mining on monitoring data from the intensive care unit

The widespread implementation of computerized medical files in intensive care units (ICUs) over recent years has made available large databases of clinical data for the purpose of developing clinical prediction models. The typical intensive care unit has several information sources from which data is electronically collected as time series of varying time resolutions. We present an overview of research questions studied in the ICU setting that have been addressed through the automatic analysis of these large databases. We focus on automatic learning methods, specifically data mining approaches for predictive modeling based on these time series of clinical data. On the one hand we examine short and medium term predictions, which have as ultimate goal the development of early warning or decision support systems. On the other hand we examine long term outcome prediction models and evaluate their performance with respect to established scoring systems based on static admission and demographic data.     

The intensive care experience: development of the ICE questionnaire

BACKGROUND: Previous research has shown that patients' reported memories of intensive care are often of unpleasant events which are described as frightening and persecutory in nature. Currently, there is no standardized way of assessing perceptions of such an experience or relating it to long-term outcome. AIMS: This paper describes the development of an intensive care experience questionnaire which aims to (a) identify the domains of such an experience, (b) assess and quantify that experience, and (c) explore its impact on short- and long-term emotional outcome. METHODS: Data from two studies are reported. Participants were non-elective patients and > or =18 years of age with an ICU stay > or =24 hours. Study 1 (n = 34) generated and developed items. Study 2 (n = 109) allowed evaluation of the factor analytic structure and psychometrics of the questionnaire. RESULTS: From a set of 31 items, exploratory factor analysis identified four components of the intensive care experience: 'awareness of surroundings' (nine items), 'frightening experiences' (six items), 'recall of experience' (five items), and 'satisfaction with care' (four items). Cronbach's alpha statistics were acceptable for each component (0.71-0.93). Correlational analysis with the subscales of the Hospital Anxiety and Depression Scale and Impact of Event Scale demonstrated concurrent and univariate predictive validity. The intensive care experience was associated with adverse emotional outcome in both the short- and long-term. DISCUSSION: The intensive care experience questionnaire identified four dimensions of experience and performed satisfactorily in these developmental analyses. Further study of an independent intensive care unit data set is necessary to confirm these findings, including the four-component structure. Development of a standardized measure provides the opportunity to increase our understanding of the intensive care experience. The questionnaire may be useful to inform the development of effective interventions to improve subsequent outcomes for these patients.