Problems following discharge after intensive care

Will he get back to normal? Survival and functional status after intensive care therapy

The study aim was to address healthcare workers' and patients' questions about the likely level of recovery at 6 months of patients admitted to an Australian intensive care unit (ICU). Ninety-three consecutive, eligible adults were identified and followed prospectively. Severity of illness on admission was assessed using Acute Physiological and Chronic Health Evaluation (APACHE II), while functional status at 6 months was evaluated using the Sickness Impact Profile (SIP). Cumulative mortality was 25%. Admission severity of illness was associated with survival at 6 months (P < or = 0.001). Fifty-one (78%) of the 70 survivors were interviewed. Admission severity of illness scores correlated with functional status at 6 months (r = 0.34, P = 0.01), a finding reported in only one other study. More than half of those interviewed had returned to near pre-admission functional status. Those with poor functional status included high proportions of people with chronic illness and head injury. Overall, physical recovery was more complete than psychosocial recovery. The findings provide useful information for addressing questions relating to physical and psychosocial recovery, appetite, sleep patterns and return to work post discharge.

Relocation stress in critical care: a review of the literature

1. Transfer to the ward following a period in intensive care may cause stress for patients. 2. A review of the literature reveals that this phenomenon has been described in a number of different ways, such as transfer stress, transfer anxiety, translocation syndrome and, more recently, relocation stress. 3. This paper reviews the various concepts before arriving at a more operational definition of the phenomenon. 4. It attempts to reveal what causes this phenomenon and to what extent it exists. 5. Patients' responses to transfer are identified and the physical and psychological problems that have been associated with discharge from intensive care are discussed. 6. Lists of interventions that the literature suggests may reduce or prevent this phenomenon from occurring are reviewed. 7. Recommendations for practice development and further research are made.

Vulnerability and security in seriously ill patients in intensive care

The purpose of this research was to gain an understanding of the experience of being a seriously ill patient in an intensive care unit (ICU). Fourteen former patients, aged 17-71 years old, who had been in ICU 3-53 days, participated in focus group interviews 3-6 months after discharge. The focus groups met 3 times each for 1.5 hours, resulting in 13-14 hours of audiotaped discussions. The transcribed data were qualitatively analysed to identify themes representing participants' experiences. Vulnerability emerged as a central concept that captured the identified themes. The data reveal that patient vulnerability while in ICU was related to extreme physical and emotional dependency. Lack of information and depersonalizing care were associated with fear, anxiety and increased vulnerability. Lack of sleep and rest also contributed to patient fear and anxiety. Vulnerability decreased when patients were kept informed of what was occurring while in ICU, received care that was personalized to their individual needs, and when their families were present. The results of this study suggest that ICU patients' vulnerability may be decreased by the security that they experience when they are adequately informed about what is happening, and when nursing and medical care is personalized to their individual needs.

Caregivers of ICU patients discharged home: what burden do they face?

Reforms in healthcare aimed at cost-cutting have led to early hospital discharge for many patients, including those who have sustained critical illness or injury requiring admission to an intensive care unit (ICU). Many former ICU patients experience ongoing health-related problems following discharge from hospital, and need ongoing support and care from their family once discharged. However, family members who take on a caregiving role often experience an enormous burden. The literature has demonstrated the impact of economic, social, physical and psychological factors on those who care for the critically ill following discharge. It is therefore essential that all nurses involved in the ongoing management of ICU patients have an understanding of the caregiving role, and consider both the patient and his/her carer in the discharge planning process. This paper reviews the literature on caregiving, and examines research studies which describe and measure the factors involved in the caregiving role. Although only a small number of studies specifically focus on caregivers of former ICU patients, findings suggest that these caregivers experience a substantial burden which is associated with the complexity of the patient's physical and psychological impairment, and complex technology. To enable nurses to incorporate planning strategies and interventions aimed at minimizing the impact on the caregiver, further research is needed to more fully explore, examine and measure the factors involved in caring for ICU patients post-discharge. Furthermore, ongoing research and evaluation of interventions will build an evidence-base to inform future practice.

Psychosocial recovery following ICU: experiences and influences upon discharge to the community

While appropriate referrals to community services upon discharge home may address the physical needs of former intensive care patients, the psychological needs may be overlooked. This pilot study describes the recovery period following discharge to home of former intensive care unit (ICU) patients and their significant others, and identifies factors influencing recovery and the role of community support in the recovery period.Semi-structured interviews were conducted with five patients and four significant others, 6 to 15 weeks following discharge from the ICU. Data were analysed using constant comparison to identify recurring categories and themes. The recovery period was characterized by the patients' focus on physical recovery with the major theme described as 'moving on', incorporating normalizing life, return to usual routines, and leaving behind the ICU experience. Factors influencing the recovery period included individual attitudes, prior experiences, the ICU experience and support of family and friends. Community support was not commonly utilized with participants describing a perceived stigma attached to asking for professional help. Attention to physical needs and care often masked the psychological support received, particularly from family members. Despite awareness of community supports, patients were generally reluctant to avail themselves of any of these services.

Hong Kong patients' experiences of intensive care after surgery: nurses' and patients' views

This study was designed to explore the lived experience of patients after elective surgery when they were being cared for in a surgical intensive care unit (ICU) in the immediate post-operative period. A phenomenological approach using unstructured interviews was employed and 10 ICU nurses and 10 patients were recruited for the study. Thematic data analysis was used. Most of the nurses believed that patients had memories of their ICU stay. Two clear categories emerged from the nurses' responses: 'perceptions of the feelings experienced by the patients' and 'perceptions of what patients experienced as support'. The nurses expressed that patients had feelings related to anxiety, pain and tiredness and they were frightened by the environment and the unknown. The nurses provided support to the patients by pre-operative visits, continuous and repeated explanation, encouraging family visits and ensuring adequate pain relief and sleep. All the patients could remember at least some of what happened during their stay in ICU. The 2 main categories which emerged from patients' responses were 'feelings experienced' and 'needs during the stay'. The patients recalled the feeling of anxiety about the reason for admission and a feeling of being safe in ICU. Six patients suffered from moderate to severe pain during movement and procedures and 2 patients complained of sleeping problems. They appreciated the preoperative visit and preferred the open unit design and flexible visiting hours. The four sub-categories: pain, sleep, pre-operative visits and family visits are discussed in detail and are reviewed in the light of other studies to compare the results. Ideas for nursing interventions to help overcome these problems are outlined and recommendations for future research are presented.

Discharge from intensive care: a view from the ward

Relocation stress is a common phenomenon in patients discharged from an intensive care unit (ICU) to a ward. A variety of nursing interventions, initiated by intensive care nurses, have been introduced following research in this area. Ward nurses are ideally situated to minimize stress in this patient population, yet their contribution has not been considered. The aim of this study was to identify the experience of the ward nursing staff when receiving a patient from the ICU. An exploratory pilot study was conducted over a 6-month period. The sample group comprised nursing staff in two wards, who regularly received ICU patients. Data collection methods were triangulated and involved the use of open-ended questionnaires and semi-structured interviews. Thirty-six questionnaires were sent, yielding a 36.1% (n = 13) response rate. Seven staff of various grades were interviewed. Data analysis was undertaken using Burnard's (1991) Thematic Content Analysis. Four major categories were identified in the analysis of the data. These were emotions; problems; communication; and interventions. However, the experience of ward staff receiving patients from intensive care differed according to grade.

The patient's thoughts and feelings about their transfer from intensive care to the general ward

This qualitative, phenomenological study was undertaken to find out how patients felt about being transferred from the intensive care unit to the ward. The six patients who took part in the study, had been in intensive care for more than 4 days. Their transfer was planned as part of their recovery from a critical illness. Following transfer to the ward, the patients were interviewed using a semi-structured approach. The interviews were audio-taped, and transcriptions from the tapes were analysed for meaning and interpretation. Findings supported the literature that was reviewed, in that transfer from intensive care to the ward was a traumatic experience for the patient, who often found it confusing, stressful and tiring. Improvements to the transfer process can be guided using the information from the literature review and findings of the study.

Research methodology issues related to interviewing the mechanically ventilated patient

Difficulties conducting research in vulnerable or frail patient populations limit the data-based information on which to base practice in these populations. Although there are many challenges in this type of research, they are not insurmountable, and, in an effort to encourage others interested in studying vulnerable patient populations, we discuss the methodological process used to prospectively study one vulnerable group. Interviews about perceptions of weaning, fatigue, mood, and sleep/rest states were conducted with 20 patients who were chronically critically ill and required long-term mechanical ventilation. Illness severity and communication difficulties were primary considerations in the design, development, and implementation of the study. Ethical considerations, informed consent, sample representation, and data collection issues are discussed.

Measuring the health outcomes of general ICU patients: a systematic review of methods and findings

Studies that have measured patient outcomes following a critical illness and admission to a general intensive care unit (ICU) have used a variety of methods and variables. Traditionally, the measures have been mortality and morbidity, but they now also include assessment of indices such as functional status, health status, quality of life and patient satisfaction. This review paper examines 31 previously published primary studies that measured patient outcomes from adult general ICUs. Inclusion criteria for the review process included papers with explicit measurement of patient outcomes beyond mortality rates: functional status, health status and quality of life. The paper includes summative descriptions of the reviewed papers, discussion of the various methods, results and limitations, and some synthesis of the pooled findings. The review indicated that the health status and activities of the majority of survivors who responded to the follow-up measures were similar to what they were before their critical illness. However, whether these subjects are representative of ICU survivors in general is not conclusive, as lack of methodological control over exclusions and losses to follow-up were evident. In addition, the heterogeneity of the ICU population in terms of age, acuity and diagnoses complicates any potential comparisons. There is an opportunity for further studies in this area by nurse researchers, in either intra- or multidisciplinary teams. Future studies should incorporate rigorous methodologies and a triangulated approach, in order to adequately examine patient outcomes following a critical illness and admission to a general ICU.

Pain and distress among elderly intensive care unit patients: comparison of patients' experiences and nurses' assessments

OBJECTIVE

To investigate elderly intensive care unit (ICU) patients' experiences of pain and distress, as well as interventions aimed at reducing these conditions, and to compare these experiences with the way nurses and assistant nurses, respectively, assess their patients' responses related to these issues.

DESIGN

Descriptive, correlational, comparative.

SETTING

Two medical-surgical ICUs at county hospitals in two medium-sized cities in Sweden.

SUBJECTS

Fifty-one elderly patients, 44 nurses, and 37 assistant nurses in two Swedish ICUs.

METHODS

Data were collected through personal interviews with patients and questionnaires completed by each nurse and assistant nurse responsible for the patients.

RESULTS

Patients' experiences of pain and distress do not fully agree with nurses' and assistant nurses' assessments; nor is there consistency between the views of nurses and those of assistant nurses. Nurses overestimated patients' breathing and intellectual problems. Assistant nurses assessed that patients received more assistance to relieve physical pain, physical discomfort, fatigue, and fear than patients reported. Compared with nurses' assessments, assistant nurses also perceived patients to suffer less from physical discomfort, breathing problems, and fatigue.

CONCLUSIONS

Nurses need more systematic procedures to assess patients' distress and pain experiences. To reduce the discrepancies observed between nurses and assistant nurses, organization of care should optimize the possibilities for the caregivers to carry out the desired assessments and interventions with a high degree of continuity and communication among staff.

Sensoristrain: an exploration of nursing interventions in the context of the Neuman systems theory

Defining what nurses do and why has been the endeavour of many researchers, both academic and clinical. Nursing interventions are a fundamental component of nursing practice and a focus on accountability means that nurses must be able to justify their actions. The sensoristrain experience of intensive care patients is widely acknowledged in nursing literature, though without the use of the word 'sensoristrain'. The aim in this paper is to place patients, their experience and the role of nurses within the practical framework of a suitable nursing theory which will elucidate and guide everyday practice in preventing and alleviating the causes (stressors), symptoms (reactions) and emotional aftermatch. Nursing interventions appropriate for the three modalities of intervention elucidated by the Neuman systems theory have been outlined, paralleled by a discussion of how these could relate to the three dimensions of nursing care: comfort care; knowing the patient; and the therapeutic presence of the nurse. Nurses must use each opportunity to advance practice through emphasizing the value of nursing in today's cost-conscious health care climate. In order to do this, and to ensure nurses' continued presence at the bedside, clear articulation of the contribution of nursing interventions to improved patient outcomes is essential.

Advanced practitioners: the hidden agenda?

Changes in health-care provision and the increased expectations of clients have precipitated major developments throughout the service. The trend towards specialist and advanced practitioners has been embraced by nurses as the route to professional recognition and increased status. The focus of this paper is consideration of the factors influencing these developments, observing the concurrent erosion of nursing values and strength. Health service management, ill-informed of nurses' function within the service, conclude that task distribution will be cost-effective. To this end, health-care assistants with National Vocational Qualifications (NVQs) performing nursing duties and nurses undertaking junior doctors' work, thereby reducing their hours, have been actively encouraged. Nurses, preoccupied with continuing debates surrounding new titles and improving status through the acquisition of medico-technical skills, have failed to consider the effects of advancing practice without first affirming their own unique identity. Nurses should appreciate the increasing risk to their own profession caused by lack of clarity and apparent compliance, which contribute to the management view of nurses as doctors' assistants--or handmaidens.

Meeting the informational, psychosocial and emotional needs of each ICU patient and family

The acquisition of counselling skills and a review of current practice within a cardiothoracic intensive care unit (ICU) have revealed the need for a nursing development that will focus on meeting the informational, psychosocial and emotional needs of patients and their families. The findings from a literature search suggest that these needs are not always adequately met. Difficulties may be encountered by patients and their families whilst trying to adjust to a stay in the ICU, to transfer to the ward, and following discharge home. Providing a client-driven service that effectively meets these complex needs could be achieved by developing a specialist role in intensive care nursing. The patients and their families could be offered provision of information and supportive strategies that extend from admission to the ICU, through transfer to a ward, and beyond. The aim of the service would be to provide patient- and family-centred continuity of care throughout the acute and rehabilitative stages of the crisis (Turner 1992). The utilization of counselling skills could help to facilitate the service, and help each client to feel supported (Tschudin 1995, p 33).

Auditing quality of nursing care

Nurses working in intensive therapy units (ITU) may perceive that they provide a good quality of nursing care to patients and relatives in the ITU. But how can this be assessed, to enable nurses to have an indication of the actual quality of nursing care? This article examines quality and audit within nursing, and then examines one of the commercially produced tools that can be utilised to give an indication of the nursing care provided within the ITU. The results of a part pilot study are imparted and then further discussed. ITU nurses need to be aware that if they do not commence auditing their nursing care then someone with no specialist knowledge may dictate to them what to do to audit their care.