Recovery from intensive care

24-hour intensive care: an observational study of an environment and events

BACKGROUND

In intensive care, patients are exposed to a strange and sometimes hostile environment, which can lead to post-traumatic psychological problems. The aim of this study was to describe an intensive care environment from a patient point of view and the events and social contacts during a patient's day.

METHODS

The study had an observational qualitative design. The data were generated by recording on DVD four adult intensive care patients in an intensive care unit over one day (n=96 hours). The DVD recording of two patients also included daylight (lx) and decibel (db) measurement. The material was analysed by inductive and deductive content analysis.

RESULTS

An intensive care patient environment is made up of physical, social and symbolic environments. The hospital, ward and patient room constitute an environment that is indirectly connected to the patient. The patient bed and all that is included in it are directly connected to the ICU patient's physical environment. The social environment includes the people who are near the patient and in direct or indirect contact with them. ICU norms, regulations, values, expectations and knowledge make up the symbolic environment. Taken together, these factors constitute an intensive care unit's way of action. The symbolic environment is connected to the social environment through people and the way of action.

CONCLUSION

The patient is connected to the ICUs environment, but is usually not able to influence it. It is important to eliminate things that prevent recovery and to promote feeling safe. Besides the physical environment, things that prevent recovery and increase a feeling of being safe can be found in both the social and the symbolic environment. We also need to learn more about ICU patients' subjective experiences in order to be able to describe the psychological environment.

The development and feasibility of a ward-based physiotherapy and nutritional rehabilitation package for people experiencing critical illness

Objective: To investigate ward-based rehabilitation after critical illness and undertake a pilot study exploring the feasibility of delivering enhanced physiotherapy and nutritional rehabilitation.

Design: Service evaluation (part A) and pilot feasibility randomized controlled trial (part B).

Setting: Hospital inpatient wards following discharge from intensive care.

Participants: Part A involved 24 people with an intensive care stay of four days or more. Part B involved 16 participants randomized into a control (n = 8) or intervention (n = 8) group.

Interventions: Part A defined the current ‘standard’ physiotherapy and nutritional interventions. In part B the control group received this ‘standard’ service while the intervention group received this ‘standard’ service plus enhanced rehabilitation.

Main measures: Part A collected process outcomes of current interventions and outcomes that included calorie and protein intake and the Rivermead Mobility Index. In part B process outcomes determined differences between groups. Outcomes included those undertaken in part A plus an incremental shuttle test, handgrip dynamometry and visual analogue scales.

Results: Part A found low levels of ward-based physiotherapy (walking and transfer practice once per week) and dietetic input (0.8 visits per week). Part B found an increased frequency of both physiotherapy (P = 0.002) and dietetic (P = 0.001) visits in the intervention group. Physical and nutritional outcomes were suitable for use after critical illness, but no statistically significant differences were found between groups. Power calculations indicated 100 participants per group would be required for a definitive study.

Conclusions: This feasibility pilot work has informed the design of a larger study to evaluate enhanced rehabilitation following critical illness.

Legacy of intensive care unit-acquired weakness

Loss of muscle mass, nerve dysfunction, and resultant weakness and functional disability represent important and lasting morbidities of an episode of critical illness. As investigators increasingly incorporate long-term functional, neuropsychological, and quality-of-life outcomes into their studies, more data are accruing that support the existence of often devastating and irreversible sequelae of severe illness and treatment in an intensive care unit. This review highlights early quality-of-life literature that supports significant physical dysfunction after intensive care unit treatment and more recent longitudinal studies up to 5 yrs after intensive care unit discharge, which clearly implicate nerve and muscle dysfunction as contributors to this reported disability. Additional follow-up work is needed to understand the pathophysiology of this injury, the spectrum of physical disability, and its associated risk factors. These data are crucial to inform risk-stratification and future rehabilitation interventions, both during the intensive care unit admission and after hospital discharge as patients reintegrate within their community and workplace.

The user experience of critical care discharge: a meta-synthesis of qualitative research

OBJECTIVES

This review identifies the most significant factors, which impact upon the user experience of progress and recovery from critical illness during the first month after discharge from critical care, and discusses these in relation to the development of effective critical care discharge support strategies.

DESIGN

Meta-synthesis of qualitative primary research.

DATA SOURCES

Qualitative research published in English between 1990 and 2009 was identified using online databases: CINAHL, MEDLINE, EMBASE, British Nursing Index, CDSR, ACP Journal Club, Cochrane library, Social Policy and Practice and PsycInfo. Studies of adult patients, relatives/carers/significant others, which focused on experiences after discharge from an intensive care or high dependency unit to a general ward were retrieved.

REVIEW METHODS

Following screening against inclusion/exclusion criteria, methodological appraisal of studies was conducted using a published framework. Ten studies met the criteria for inclusion.

RESULTS

Five key themes emerged from the meta-synthesis: physical and psychological symptoms; making progress; the need to know; and safety and security.

CONCLUSIONS

Findings from this meta-synthesis and other related literature supports the existence of physical and psychological problems in the immediate period following discharge from critical care to the ward, and suggests that patients and their families have a desire for more control over their recovery. However, this desire is countered by a need to feel safe and protected, culminating in an expression of dependence on healthcare staff. Any effective support strategy needs to take account of these findings.

Strategies for promoting early activity in critically ill mechanically ventilated patients

Prolonged immobilization plays a significant role in neuromuscular abnormalities and complicates the clinical course of a majority of critically ill patients. Immobilization in critically ill patients is associated with significant morbidity and impaired physical function. Overuse of sedation, sleep deprivation, immobility, and the development of delirium are all intensive care unit (ICU) factors that may negatively impact patient outcomes. Ambulation of critically ill patients is difficult with risk for adverse events. However, with a dedicated and trained team and culture change, early ICU mobility can be a feasible and safe process. Early mobility has potential as a therapy to prevent or treat the neuromuscular complications of critical illness. ICU culture can be transformed in a way that leads to improved and more reliable treatments and care, including early activity and mobility.

Development of the 3-SET 4P questionnaire for evaluating former ICU patients' physical and psychosocial problems over time: a pilot study

BACKGROUND

Current studies reveal a lack of consensus for the evaluation of physical and psychosocial problems after ICU stay and their changes over time.

OBJECTIVES

The aim was to develop and evaluate the validity and reliability of a questionnaire for assessing physical and psychosocial problems over time for patients following ICU recovery.

PATIENTS

Thirty-nine patients completed the questionnaire, 17 were retested.

METHODS AND RESULTS

The questionnaire was constructed in three sets: physical problems, psychosocial problems and follow-up care. Face and content validity were tested by nurses, researchers and patients. The questionnaire showed good construct validity in all three sets and had strong factor loadings (explained variance >70%, factor loadings >0.5) for all three sets. There was good concurrent validity compared with the SF 12 (r(s)>0.5). Internal consistency was shown to be reliable (Cronbach's alpha 0.70-0.85). Stability reliability on retesting was good for the physical and psychosocial sets (r(s)>0.5).

CONCLUSION

The 3-set 4P questionnaire was a first step in developing an instrument for assessment of former ICU patients' problems over time. The sample size was small and thus, further studies are needed to confirm these findings.

Effect of penetrating trunk trauma on the recovery of adult survivors: a pilot study

Gunshot and/or stab wounds to the trunk are injuries seen in South African hospitals. Patients are managed in the intensive care unit. Prolonged mechanical ventilation with immobilization results in some degree of muscle dysfunction. Our goal was to determine if patients recover adequately spontaneously following critical illness. No formal rehabilitation programmes exist in South Africa for these patients following discharge. A prospective, observational study was conducted. Patients were recruited from three ICUs in Johannesburg. Lung function tests, dynamometry, quality of life, 6-minute-walk, and oxygen uptake tests were performed over 6 months following discharge from the hospital. The control group consisted of existing data for healthy volunteers. Distance walked during 6-minute-walk test was significantly reduced for the study group compared to the control group (1 month [p = 0.00251]; 6 months [p = 0.0355]). At 1 month there was a significant reduction in quadriceps and triceps strength for the study group compared to the control group (p = 0.0089; p = 0.0246, respectively). Quadriceps strength remained significantly reduced for the study group (3 months [p = 0.0489]). No difference in muscle strength was detected between the groups at 6 months. Actual and predicted residual volumes differed significantly for the study group (1 month [p = 0.0034]; 6 months [p = 0.0157]). A trend of muscle weakness (to 3 months), poor exercise capacity, and abnormal lung volumes was identified. A formal rehabilitation programme may be needed to address these disabilities.

Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority

OBJECTIVE

Ambulation of patients with acute respiratory failure may be unnecessarily limited in the acute intensive care setting. We hypothesized that ambulation of patients with acute respiratory failure would increase with transfer to an intensive care unit where activity is a key component of patient care.

DESIGN

Pre-post cohort study of respiratory failure patients.

SETTING

Adult intensive care units at LDS Hospital.

PATIENTS

Respiratory failure patients requiring >4 days of mechanical ventilation who were transferred from other LDS Hospital intensive care units to the respiratory intensive care unit.

INTERVENTIONS

We prospectively applied an early activity protocol to all consecutive respiratory failure patients transferred to the respiratory intensive care unit.

MEASUREMENTS AND MAIN RESULTS

We studied 104 respiratory failure patients who required mechanical ventilation for >4 days. Transferring a patient to the respiratory intensive care unit substantially increased the probability of ambulation (p < .0001). After 2 days in the respiratory intensive care unit, the number of patients ambulating had increased three-fold compared with pretransfer rates. Female gender (p = .019), the absence of sedatives (p = .009), and lower Acute Physiology and Chronic Health Evaluation II scores (p = .017) also predicted an increased probability of ambulation. Improvements in ambulation with transfer to the respiratory intensive care unit remained significant after adjustment for Acute Physiology and Chronic Health Evaluation II scores and other covariates.

CONCLUSIONS

Transfer of acute respiratory failure patients to the respiratory intensive care unit substantially improved ambulation, independent of the underlying pathophysiology. The intensive care environment may contribute unnecessary immobilization throughout the course of acute respiratory failure. Sedatives, even given intermittently, substantially reduce the likelihood of ambulation. Controlled studies are needed to determine whether intensive care unit immobilization contributes to long-term neuromuscular dysfunction or whether early intensive care unit activity improves outcomes.

Physical consequences of critical illness

Patients who survive critical illness are at risk of permanent physical and functional deficits which decrease the health-related quality of life. The reasons for physical morbidity include the nature of and treatment for the inciting critical illness, new decrements in organ function and worsening of pre-existing organ dysfunction, and prolonged physical immobility and long intensive care unit stay.

Sexual dysfunction in intensive care survivors

Normal sexual function is an important component of a patient's overall health status. Sexual dysfunction has been described in a variety of patient populations including survivors of critical illness. This review gives an overview of the issues pertaining to sexual dysfunction in patients who have experienced intensive care unit treatment.

Transfer out of intensive care: a qualitative exploration of patient and family perceptions

OBJECTIVE

To examine perceptions of ICU transfer held by patients and their family members, focusing specifically on those aspects of transfer perceived as difficult and those perceived as helpful.

DESIGN

Descriptive qualitative case study design.

SETTING

General ICU of a large regional Australian teaching hospital.

PATIENTS

A total of 7 patients and 6 family members were purposefully recruited at one-month post-discharge from hospital. Participants were selected for their ability to recall ICU transfer, the involvement of family members and their ability to articulate their experiences.

MAIN OUTCOME MEASURES

Two focus groups (one for patients and one for families) were conducted in the hospital setting, aimed at capturing the individual and collective perceptions of transfer out of intensive care.

RESULTS

Four themes emerged from the data that reflected the complex and emotional nature of transfer out of intensive care. These themes included (1) a sense of sudden abandonment (2) pervasive feelings of vulnerability and helplessness, (3) a loss of importance and (4) ambivalence about the experience.

CONCLUSIONS

The need for ICU nurses, ward nurses and affiliated healthcare professionals to provide emotional support throughout ICU transfer is the most significant implication of the study. Strategies to provide this support must be developed, implemented and evaluated.

The extent and application of patient diaries in Danish ICUs in 2006

The aim of this study was to describe the extent and application of patient diaries in Danish intensive care units (ICUs) in 2006. Following critical illness, many patients experience disturbed and disconnected memories. Patient diaries in the ICU have been introduced locally by nurses in the Scandinavian countries and the UK as a means to improve cognitive recovery and prevent psychological trauma following critical illness. Descriptive design, using qualitative key informant telephone interviews (n= 19) was used as the source of data. A semi-structured interview guide was used and field notes from the interviews were mailed to the informants for verification and additional information. Nineteen out of 48 Danish ICUs use patient diaries. Patient diaries are mainly used for sedated, ventilated patients during critical illness. The purpose of diaries was mainly to assist memory due to post-ICU amnesia. There was no systematic follow-up after the ICU stay. The study showed a number of legal and ethical issues that still need to be resolved. Patient diaries are ambiguous documents that are neither the property of the hospital nor the patient. The diaries have been implemented at Danish ICUs without a plan for the assessment of their effect, thus bypassing established control mechanisms that evaluate the usefulness of an intervention, such as Health Technology Assessment or nursing research.

Seven lessons from 20 years of follow-up of intensive care unit survivors

PURPOSE OF REVIEW

Through a personal narrative, the authors discuss the lessons they have learned from 20 years of intensive care follow-up and rehabilitation.

RECENT FINDINGS

There is a greater understanding of the legacies of the physical, psychological and cognitive problems after critical illness, and new momentum toward developing and delivering practical care to both survivors of intensive care and their relatives.

SUMMARY

The need and demand for care after critical illness is now firmly established.

A qualitative study exploring patients perceived quality of life following an emergency liver transplant for acute liver failure

Liver transplantation is now an accepted and successful therapy for both acute and chronic liver diseases. Whilst the study of health related quality of life (HRQoL) post-transplantation for chronic liver disease (CLD) has been well documented, there is little data measuring HRQoL following liver transplantation for acute liver failure (ALF), despite super urgent transplantation constituting 16.6% of all United Kingdom liver transplantation. Therefore, the aim of the present study was to document the HRQoL in patients who have received an emergency liver transplant for ALF. Data collection employed between method triangulation, using the Short Form 36 quality of life health questionnaire for both ALF (n=47) and CLD (n=49), and six semi-structured interviews. Only the qualitative element of the study is reported here. Phenomenological analysis of the semi-structured interviews identified four themes relating to the physical changes encountered (inactivity), physical recovery (health transition); changes made to the transplant recipients life styles (modification); and outlook. The majority of transplanted ALF transplant recipients' stated that they have a good quality of life, which was often comparable to their pretransplantation lifestyle. However, the initial recovery process was often difficult and was related to the physical changes instigated from their multi-organ failure and intensive care stay, which can present numerous physical and emotional challenges.

Diaries written for ICU patients

Diaries are written for critically ill patients, to help them understand their intensive care stay and come to terms with their illness. The aim of this content analysis of eight such diaries is to understand the potential benefits for patients and families of this care intervention. A main category emerged: Sharing throughout the ICU time. Four themes were identified: (a) Sharing the story, (b) Sharing the presence, (c) Sharing feelings, and (d) Sharing through support. The first theme reflects the narration of daily events. The second is the perceived presence of health professionals and family at the patient's bedside and the presence of the patient as a person through the diary entries. The third theme describes the expression of feelings as written throughout the text. The last theme refers to the support offered to the patient. The diaries reflect the commitment and care of contributors to the patients' welfare.

Patient empowerment: does it still occur in the ICU?

The theoretical underpinnings of patient empowerment were developed through the work of educators and community psychologists, working primarily with the socially disadvantaged. Empowerment is seen as a philosophy based upon the belief of the inherent worth and creative potential of each individual. Therefore, the aim of this paper is to explore whether this creative potential associated with patient choice that encapsulates empowerment is applicable to the Intensive Care Unit.

Physical and psychological sequelae of critical illness

OBJECTIVES

To measure levels of anxiety, depression and post-traumatic stress among survivors of a critical illness and to relate these symptoms to general health parameters.

DESIGN

A prospective study of patients who had spent a minimum 3 days (median 9 days) in a general intensive care unit (ICU). Of these patients, 51 were interviewed 3 months after discharge and 45 of them were reviewed at 9 months.

METHODS

General health was assessed by a physical symptom score, the EuroQol 'thermometer' and the Short Form 36 (SF-36) questionnaire. Physical and mental component summary measures (PCS, MCS) were calculated from the SF-36 data. Psychological health was assessed using both the Hospital Anxiety and Depression Scale and the Impact of Events Scale.

RESULTS

At both 3 and 9 months after ICU discharge 24% of patients qualified as a 'case' of anxiety, while similar figures were seen for intrusion (24 and 20%). The incidence of depression (35 and 47%) and avoidance (36 and 38%) was higher on each occasion. Four of the eight SF-36 domains improved with time, as did PCS (from 29.0 to 35.4), but there was no significant difference in physical symptom score, EuroQol value or MCS. Strong correlations were seen between the physical and psychological parameters at each time point.

CONCLUSIONS

A substantial proportion of patients who survive a critical illness show evidence of anxiety and depression up to 9 months later, and most of them also have symptoms indicative of post-traumatic stress. Delayed physical recovery may contribute to this psychological morbidity. ICU follow-up clinics should be able to detect patients suitable for psychological intervention.

The epidemiology of major joint contractures: a systematic review of the literature

Current knowledge on the epidemiology of major joint contractures is limited. We systematically reviewed the literature to identify studies examining the epidemiology of joint contracture regardless of clinical condition. Epidemiologic measures of interest were prevalence, incidence, and prognostic risk factors. We used Medline to identify all epidemiologic studies of major joint contractures published from 1966 to March 2005. There was a high prevalence of major joint contractures. Most studies focused on one joint rather than including all relevant major contractures. However, most studies did provide a definition of a contracture or the measures used to assess contractures. Immobility is a highly prevalent disability in at-risk populations, and constitutes a tremendous burden to patients in nursing homes, hospitals, and the outpatient community. The lack of epidemiologic data is a major impediment to providing appropriate treatment.

After critical care: a study to explore patients' experiences of a follow-up service

AIMS AND OBJECTIVES

To establish patients' experiences after discharge from critical care and to evaluate implementation of a follow-up service.

BACKGROUND

Government recommendations advise critical care follow-up to prevent readmission and address problems after discharge. Admission to critical care results in significant psychological and physiological sequelae.

DESIGN

A prospective, longitudinal and exploratory study of surgical cancer patients requiring >48 hours in critical care. Qualitative interviews were conducted and short questionnaires were used.

METHODS

Patient Expert Advisory Groups were invited to participate in research design. Patients were visited in the ward at days 1 and 5 after discharge, invited to nurse-led follow-up clinic and interviewed at three and six months. Short questionnaires were administered at six and 12 months.

FINDINGS

Twenty-seven patients participated in the study. All patients experienced benefit from the service. Emergent themes included: rehabilitation from critical care: physiological issues and needs, memories: real and unreal, uncertainty and fear and empathy. A core theme of reassurance was underlying through the research. Issues while in critical care included: the need for nursing presence, nightmares, delusions, confusion, fear of ward transfer, inability to remember, disorientation and being prepared for the experience. After discharge, issues shifted to longer term needs. Psychological support, in the form of the follow-up clinic, proved useful. The ability to move on with life after discharge varied and uncertainty about the future and their cancer had an impact upon this. Recovery was made easier through the follow-up clinic. Patients required reassurances that their experiences were valid and also wanted reassurances about their cancer.

CONCLUSION

Critical care causes various difficulties for patients that may impinge on recovery. Incorporating patients into the design process helps identify needs more closely. Follow-up proved beneficial and highlighted the role nurses have in improving patient experiences after discharge from critical care. Nurses should be vigilant for both immediate and longer-term needs.

RELEVANCE TO CLINICAL PRACTICE

This research into nurse-led follow-up clinics after critical care highlights an important, and often neglected, part of the critical illness continuum. Attending such clinics may help reassure patients after discharge from critical care.

Early activity is feasible and safe in respiratory failure patients*

OBJECTIVE

To determine whether early activity is feasible and safe in respiratory failure patients.

DESIGN

Prospective cohort study.

SETTING

From June 1, 2003, through December 31, 2003, we assessed safety and feasibility of early activity in all consecutive respiratory failure patients who required mechanical ventilation for >4 days admitted to our respiratory intensive care unit (RICU). A majority of patients were treated in another intensive care unit (ICU) before RICU admission. We excluded patients who required mechanical ventilation for < or =4 days.

PATIENTS

Eight-bed RICU at LDS Hospital.

INTERVENTIONS

We assessed patients for early activity as part of routine respiratory ICU care. We prospectively recorded activity events and adverse events. We defined three activity events as sit on bed, sit in chair, and ambulate. We defined six activity-related adverse events as fall to knees, tube removal, systolic blood pressure >200 mm Hg, systolic blood pressure <90 mm Hg, oxygen desaturation <80%, and extubation.

MEASUREMENTS AND MAIN RESULTS

During the study period, we conducted a total of 1,449 activity events in 103 patients. The activity events included 233 (16%) sit on bed, 454 (31%) sit in chair, and 762 (53%) ambulate. In patients with an endotracheal tube in place, there were a total of 593 activity events, of which 249 (42%) were ambulation. There were <1% activity-related adverse events, including fall to the knees without injury, feeding tube removal, systolic blood pressure >200 mm Hg, systolic blood pressure <90 mm Hg, and desaturation <80%. No patient was extubated during activity.

CONCLUSIONS

We conclude that early activity is feasible and safe in respiratory failure patients. A majority of survivors (69%) were able to ambulate >100 feet at RICU discharge. Early activity is a candidate therapy to prevent or treat the neuromuscular complications of critical illness.

Early Intensive Care Unit Mobility: Future Directions

In the previous articles in this issue of Critical Care Clinics, care of the critically ill patient was explored from the viewpoint of how intensive care unit (ICU) mobilization may benefit patients, and how our usual practice may impede the delivery of early mobilization. In this article, the authors discuss future directions in this area under the following headings: current limitations in understanding the effect of immobility on muscle and nerve, uncertainty about the risks and benefits of early mobility, how to implement early mobility programs, and ICU process of care issues required to facilitate early mobilization. Finally, we present a "roadmap" outlining future directions moving toward the development and testing of early ICU mobility therapies.

[Recall and memory after intensive care unit stay. Development of posttraumatic stress disorder]

BACKGROUND AND OBJECTIVE

The intensive care unit (ICU) confers a stress on patients and may affect the memory. The aim of the study was to examine the memory after critical care and the relationship with therapy and the development of posttraumatic stress disorder.

PATIENTS AND METHOD

Prospectively study conducted between December 2001 and June 2003. Patients were excluded if language difficulties or had a neurologic or psychiatric disease. We collected data on gender and age, length of stay in the ICU, severity of acute illness, diagnoses and medical treatment with mechanical ventilation, propofol, midazolam and dopamine during the ICU stay. 12 months after ICU eligible patients were contacted to assess memory. The ICUM (Intensive Care Memory) tool and IES (Impact Event Scale) were used to assess memory and posttraumatic stress disorder.

RESULTS

A total of 169 patients were included. The incidence of memory was 77.6%. 41 patients recalled delusional memories and these patients had higher IES after discharge. The logistic regression suggested a relationship with propofol, dopamine and length of stay.

CONCLUSIONS

ICU treatment may be related more to recall of delusions. The delusional memory is associated with posttraumatic stress disorder symptoms after ICU.

A national survey of intensive care follow-up clinics

Intensive care follow-up clinics allow extended review of survivors of critical illness. However, the current provision of intensive care follow-up clinics in the UK is unknown. We performed a survey of intensive care follow-up clinic practice in the UK. A questionnaire was sent to 298 intensive care units in the UK to determine the number of follow-up clinics and details of current follow-up practice. Responses were received from 266 intensive care units, an 89% response rate. Eighty units (30%) ran a follow-up clinic. Only 47 (59%) of these clinics were funded. Of those intensive care units without a follow-up clinic, 158 (88%) cited 'financial constraints' as the reason. Over half of the follow-up clinics (44 clinics, 55%) were nurse-led, and the majority (56 clinics, 77%) only routinely review patients treated on the intensive care unit for 3 or 4 days or longer. Nearly half of the follow-up clinics (39 clinics, 49%) have pre-negotiated access to at least one other out-patient service.

Patients' dreams in ICU: recall at two years post discharge and comparison to delirium status during ICU admission. A multicentre cohort study

Discharged intensive care unit (ICU) patients often recall experience vivid dreams, hallucinations or delusions. These may be persecutory in nature and are sometimes very frightening. It is possible that these memories stem from times when the patient was experiencing delirium, a common syndrome in the critically ill. Routine screening for delirium in ICU is becoming more prevalent, however, little has been published comparing the objective development of delirium (patient observations using screening tools) and patients' subjective recollection of dreams and unreal experiences in the ICU. This study describes the relationship between observed behaviour during ICU admission and the subjective memories of ICU experiences amongst 41 participants in three ICUs up to 24 months post discharge. Overall, 44% of patients (n=18) recalled dreams during their ICU admission. There was a trend to increased prevalence of dreaming (50% versus 39%) amongst the 18 patients who were delirious during their ICU admission than in the 23 non-delirious patients. Dreaming was significantly associated on logistic regression with increased length of stay (OR 1.39, 95% CI 1.08-1.79, p=0.01), but not delirium status (OR 1.56, 95% CI 0.45-5.41, p=0.49). A longer ICU stay was significantly associated with the experience of ICU dreaming. As many dreams are disturbing, we suggest providing information and counselling about delirium to patients who remain in ICU for longer periods.

Case report: inspiratory muscle training in chronic critically ill patients--a report of two cases

BACKGROUND AND PURPOSE

Inspiratory muscle weakness and fatigue has been documented following prolonged mechanical ventilation despite successful weaning from mechanical ventilation. This report describes the application of inspiratory muscle training in two patients following successful discharge from an intensive care unit (ICU) after prolonged mechanical ventilation.

METHODS

Both patients undertook inspiratory muscle training in conjunction with standard physiotherapy rehabilitation.

RESULTS

Improvements in inspiratory muscle strength and endurance, exercise tolerance and functional performance following twice-daily inspiratory muscle training were recorded. In both cases, an improvement in maximal inspiratory pressure (MIP) and maximal tolerated inspiratory load (MIP(load)) was found following training.

CONCLUSION

These positive results indicate further research is needed to investigate the effect of inspiratory muscle training on respiratory function, exercise tolerance and functional performance, for the possible inclusion of inspiratory muscle training into the physiotherapy management of patients following prolonged mechanical ventilation.

Re-admission to intensive care: identification of risk factors

BACKGROUND AND PURPOSE

The re-admission of patients to intensive care is associated with increased morbidity, mortality, loss of morale for patients and family, and increased health costs. The aim of the present study was to identify factors which place patients at a higher risk of re-admission to intensive care.

METHOD

A prospective study of patients who were re-admitted to a 22-bed tertiary level intensive care facility within a 12 month period. Data were kept on every patient re-admitted to intensive care, including standard demographic data, initial admission diagnosis, co-morbidities, re-admission diagnosis, mobility on discharge, secretions, airway, chest X-ray, PaCO2, PaO2, PaO2/FiO2 and time of discharge. Subjects included 74 patients who had been re-admitted to intensive care in 12-month period and a comparison group of patients who were not re-admitted to intensive care. A cross-tabs procedure was initially used to estimate maximum likelihood. Significant factors with an alpha value of <0.10 were entered into a backward conditional binary logistic regression to determine independent factors.

RESULTS

The overall percentage of patients who were re-admitted to intensive care compared with total admissions was 7.7%. Significant independent factors for re-admission were found to be age >65 years (p<0.05), colonization (p<0.001), weakness (p<0.001), co-morbidities of cardiac and/or respiratory disease (p<0.001) and depression (p<0.001).

CONCLUSIONS

A certain profile of patients has been established who are at increased risk of re-admission to intensive care. These patients could be provided with increased intervention and surveillance on discharge from intensive care.

Neuromuscular sequelae of critical illness

PURPOSE OF REVIEW

To investigate the impact of critical illness polyneuropathy and critical illness myopathy on short-term and long-term patient outcome.

RECENT FINDINGS

In the acute-care setting, critical illness polyneuropathy and critical illness myopathy are important causes of acute paralysis in critically ill comatose patients, and may cause inappropriately pessimistic prognoses. Duration of weaning from artificial ventilation is 2 to 7 times greater in patients with critical illness polyneuropathy than in patients without critical illness polyneuropathy. After intensive care unit and hospital discharge, many patients diagnosed with critical illness polyneuropathy or critical illness myopathy are reported to complain of profound muscle weakness. Chronic disability was a common finding among them. Complete functional recovery with patients regaining the ability to breathe spontaneously and to walk independently was reported in 180 of 263 patients (68.4%); severe disability with tetraparesis, tetraplegia, or paraplegia was reported in 74 patients (28.1%). Persisting milder disabilities were common even in patients with complete functional recovery, and included reduced or absent deep tendon reflexes, stocking and glove sensory loss, muscle atrophy, painful hyperesthesia, and foot drop. An association of critical illness polyneuropathy and critical illness myopathy with increased intensive care unit and hospital mortality has been demonstrated only in selected intensive care unit populations; data are insufficient to demonstrate any association with long-term mortality.

SUMMARY

Intensive care unit-acquired critical illness polyneuropathy and critical illness myopathy influence the evaluation of acutely ill comatose patients and may instigate unreasonably pessimistic prognosis. Critical illness polyneuropathy and critical illness myopathy are an important cause of difficult weaning of patients from the ventilator and of persisting muscle weakness and disability after intensive care unit discharge.

Epidemiology and treatment of psychiatric conditions that develop after critical illness

PURPOSE

As a greater number of patients survive critical illness, there is increasing interest in accelerating patients' recovery after intensive care unit discharge. There is compelling evidence that psychiatric illnesses such as depression impair functional status in patients with chronic medical illnesses. Therefore, psychiatric conditions that develop after critical illness are a logical target for treatment or prevention strategies to improve recovery after critical illness.

RECENT FINDINGS

This is a new area of investigation for intensive care unit researchers. To date, most studies have focused on descriptive epidemiology of psychiatric conditions at varying times after intensive care unit discharge. Small randomized trials have shown that depression and posttraumatic stress symptoms can be reduced by interventions during or after mechanical ventilation, although the causal mechanisms leading to these improved outcomes are obscure. Promising results must be confirmed in additional trials. After acute myocardial infarction, large trials have found that psychosocial interventions started after hospital discharge are ineffective at preventing psychosocial impairment.

SUMMARY

Psychiatric symptoms and disorders affect 15%-35% of patients months after intensive care unit discharge. There is no consistent evidence that antidepressant medications are safe or effective in critically ill patients. Understanding the causal pathways that lead from acute medical stress to neuronal alterations and subsequent psychiatric symptoms will allow more precise targeting of preventive interventions.

A qualitative study of the experiences of patients following transfer from intensive care

In nursing literature much attention has been paid to patients' experiences while in intensive care. Extensive literature exists examining the longer-term effects of critical care [Jones C, Humphris GM, Griffiths RD. Psychological morbidity following critical illness - the rationale for care after intensive care. Clinical Intensive Care 1998;9:199-205; Griffiths RD, Jones C. ABC of intensive care. Recovery from intensive care. Br Med J 1999;319:417-429]. There is an apparent scarcity of data examining patients' experiences immediately following discharge to wards. A Husserlian phenomenological approach was utilised to gain some understanding of the experience of patients following transfer from intensive care. Ten patients selected purposively comprised the sample. Interviews were performed on the wards 3-5 days following transfer from intensive care. Data was analysed utilising () [Colaizzi PF. Psychological Research as the phenomenologist views it. In: Valle R, King M, editors. Alternatives for psychology. New York: Oxford University Press; 1978. p. 48-71] procedural approach to phenomenological interpretation and analysis. Three major themes emerged: physical response, psychological response and provision of care. These provide a possible framework for patient assessment. Implications for future practice and study are discussed.

Standing with the assistance of a tilt table improves minute ventilation in chronic critically ill patients

OBJECTIVE

To investigate the effect of standing with assistance of the tilt table on ventilatory parameters and arterial blood gases in intensive care patients.

DESIGN

Consecutive sample.

SETTING

Tertiary referral hospital.

PARTICIPANTS

Fifteen adult patients who had been intubated and mechanically ventilated for more than 5 days (3 subjects successfully weaned, 12 subjects being weaned).

INTERVENTION

Passive tilting to 70 degrees from the horizontal for 5 minutes using a tilt table.

MAIN OUTCOME MEASURES

Minute ventilation (VE), tidal volume (VT), respiratory rate, and arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2).

RESULTS

Standing in the tilted position for 5 minutes produced significant increases in VE (P <.001) and produced both increases in respiratory rate (P <.001) and VT (P =.016) compared with baseline levels. These changes were maintained during the tilt intervention and immediately posttilt. Twenty minutes after the tilt, there were no significant changes in ventilatory measures of VE, VT, or arterial blood gases PaO2 and PaCO2 compared with initial values.

CONCLUSIONS

Standing for 5 minutes with assistance of a tilt table significantly increased ventilation in critical care patients during and immediately after the intervention. There were no improvements in gas exchange posttilt. Using a tilt table provided an effective method to increase ventilation in the short term.

Returning home after intensive care: a comparison of symptoms of anxiety and depression in ICU and elective cardiac surgery patients and their relatives

OBJECTIVE

This study gathered data on symptoms of anxiety and depression in patients and relatives after discharge from intensive care and examined whether the intensive care population differ from an elective cardiac surgery group with regards to their anxiety and depression symptom reporting.

DESIGN AND SETTING

A single measurement point matched group comparison study in an ICU follow-up programme.

PATIENTS AND PARTICIPANTS

Twenty ICU patients and their relatives and a matched comparison group of 15 elective cardiac surgery patients and their relatives.

MEASUREMENTS AND RESULTS

Patients and relatives completed the Hospital Anxiety and Depression Scale. Relatives answered an open question to explore the perceived impact of Intensive care/cardiac surgery on their lives. ICU patients' relatives reported significantly higher number of symptoms of anxiety than did ICU patients, higher number of symptoms of depression than cardiac surgery patients' relatives, and more troubling and life-altering experiences than the relatives of cardiac surgery patients.

CONCLUSIONS

Relatives of ICU patients also suffer anxiety and depression, and services should address this need. Group differences suggest that ICU patients' relatives have "unique" characteristics of depression symptom reporting.

Meeting patient and relatives' information needs upon transfer from an intensive care unit: the development and evaluation of an information booklet

BACKGROUND

Transfer from the intensive care unit to a ward is associated with a significant degree of relocation stress for patients and relatives. This can be stressful for ward nurses due to the dependency levels of patients and the ensuing increased workload. Furthermore the patient may require care, not normally undertaken in that clinical area, e.g. tracheostomy care. Patients may forget the verbal information given to them at the time of transfer and often have limited or no memory of the intensive care unit experience. This can cause anxiety and compound the feelings of stress associated with transfer. Many patients suffer psychological and physiological problems after intensive care unit, which can affect their recovery and quality of life.

AIMS

The aim of the study was to develop an evidence-based information booklet for patients and relatives preparing for transfer from intensive care units.

DESIGN

This collaborative study used an exploratory design with elements of the action research cycle. The study, conducted in three phases, involved identifying patients' and relatives' information needs around the time of transfer; designing and developing an information booklet; and the introduction and evaluation of the booklet into practice.

METHODS

Semistructured interviews were used to elicit the views of patients and relatives regarding their information needs. Members of the multidisciplinary team were involved in identifying and reviewing booklet content.

RESULTS

Evaluation identified positive outcomes relating to patients' and relatives' satisfaction with the information and enhanced communication with other wards and health care professionals. The study also highlighted the need for more staff education in relation to patients and relatives needs when transferring to a ward.

CONCLUSIONS

This study has demonstrated the value of providing patients and relatives with written information regarding transfer from intensive care units. Furthermore the study confirmed the feasibility and importance of including patients and relatives in the process of booklet development to ensure that their needs for information are being met.

RELEVANCE TO CLINICAL PRACTICE

Providing written information as part of a structured discharge plan is recommended. It provides patients and relatives with a resource that they can refer to at any time and that enhances verbal communication. The purpose of this information is to inform and empower patients so that they are better prepared for the transfer and recovery period.

Standing with assistance of a tilt table in intensive care: A survey of Australian physiotherapy practice

Although tilt tables are used by physiotherapists to reintroduce patients to the vertical position, no quantitative evidence is available regarding their use within intensive care units (ICUs) of Australian hospitals. The purpose of this study was to evaluate the use of tilt tables in physiotherapy management of patients in ICUs across Australia. Ninety-nine physiotherapists working in Australian public ICUs were contacted via mail and asked to complete a questionnaire regarding their use of tilt tables in practice. Reasons for the use of the tilt table, contraindications, commonly used adjuncts, monitoring, and outcome measures were also investigated. Eighty-six questionnaires were returned (87% response). The tilt table was used by 58 physiotherapists (67.4%). The most common reasons for inclusion of tilt table treatment were to: facilitate weight bearing (94.8% of those who tilt); prevent muscle contractures (86%); improve lower limb strength (81%); and increase arousal (70%). The tilt table was most frequently applied to patients with neurological conditions (63.8%) and during long-term ICU stay (43.1%). Techniques often combined with tilt table treatment included upper limb exercises (93.1%) and breathing exercises (86.2%). Standing with assistance of the tilt table is used by the majority of physiotherapists working in Australian ICUs. A moderate level of agreement is demonstrated by physiotherapists regarding indications to commence tilt table treatment and adjunct modalities combined with standing with assistance of the tilt table.

Follow-up after intensive care: a single center study

OBJECTIVES

To study health problems, quality of life, functional status, and memory after intensive care.

SETTING

Adult patients ( n=346) discharged from a university hospital ICU.

DESIGN AND METHODS

Prospective cohort study. Follow-up patients were found using the ICU database and the Peoples Registry. Quality of life (QOL) was measured with the Short Form 36 (SF-36) 6 months after ICU discharge. Semi-structured interviews, questionnaires, Glasgow Outcome Score (recovery), and Karnofsky Index (functional status) were used at consultations 7-8 months after ICU discharge.

RESULTS

The SF-36 response rate was 64.5%, with scores significantly lower than population scores. Consultation patients ( n=136) did not differ from the rest ( n=210) regarding age, SAPS II scores, length of stay (LOS), and reasons for ICU admission. At follow-up 67.6% of consultation patients continued most activities, 75% looked after themselves, and 64.7% were non-workers, compared to 40.4% before the ICU admission. During and after the ICU stay, 40% lost more than 10 kg body weight. Fifty-eight (43%) could not remember anything from their ICU stay. At follow-up only 22 (16%) could remember having received information during their ICU stay. Three patients needed referral to other specialties.

CONCLUSIONS

We should focus more on optimizing symptom management and giving repeated information after ICU discharge. Nutritional status and weight loss is another area of concern. More research is needed to find out how the broad range of psychosocial and physical problems following an ICU stay relates to the stay.

Following the path of ICU survivors: a quality-improvement activity

Recent interest in continuity of care has meant that the illness trajectory experienced by intensive care unit (ICU) patients has received more attention. Using continuous quality improvement as a framework, this paper describes information obtained during a 3-year period relating to ICU patients' long-term experiences after being discharged from hospital. This information identified that most participants had been discharged home but that many experienced problems with mobility, disability and fatigue. Changes in employment status and the need for financial assistance were noted. As a result of the information provided by this activity, clinical practice has changed and a number of formal research studies have been undertaken.

The physiological after-effects of critical care

After a stay in intensive care, patients may suffer physiological after effects, such as muscle wasting, polyneuropathies, disturbed sleep, itching and poor mobility. The care that patients receive whilst on intensive care may contribute to the severity of some of these physical problems. Raising awareness amongst critical care nurses may help reduce the severity of some of the physiological after effects. Increased awareness amongst nurses on the wards about the physical impact of intensive care may lead to a greater understanding of the needs of this group of patients and may improve discharge planning.

Immediate follow-up after ICU discharge: establishment of a service and initial experiences

Follow-up of patients discharged from the intensive care unit (ICU) is recommended as a means of service evaluation (Department of Health (2000). Comprehensive Critical Care: a Review of Adult Critical Care Services), in order to monitor the quality of the services provided Without patient follow-up, ICU staff have only 'death' or 'discharge alive from hospital' as clinical outcomes from which to judge practice performance, and limited evidence exists on which to base decisions about improvements to critical care practice (Audit Commission (1999). Critical to Success--the Place of Efficient and Effective Critical Care Services Within the Acute Hospital) To address these issues the Regional Intensive Care Unit (RICU) obtained information from patient assessment/interview on problems experienced by patients within 8-9 days (mean), following discharge from RICU A nurse-administered questionnaire was used to identify functional outcomes, nutrition and psychological issues such as anxiety and sleep disturbances Benefits of patient follow-up introduced and planned include: patient diaries for long-term patients, input from clinical psychologis, review of sedation used in RICU.

Psycho-affective disorder in intensive care units: a review

This paper reviews the literature related to the Intensive Care Unit (ICU) Syndrome. The intention of the paper is to explore the range of psychotic and affective phenomena that may be observed in practice, together with the management of contributory stressors. Patients experience a range of psycho-affective disturbances that may be triggered by drugs, the environment, dehumanizing practices and sleep deprivation. Symptoms do not always disappear following discharge and further research is required to determine the long-term psychological effects of an ICU. Comprehensive assessment of the patient's psychological state, using an appropriate tool, is necessary and should form an integral part of ongoing care. Interventions identified include eradication of dehumanizing behaviour, modification of environmental stimuli, effective communication and therapeutic touch. Where possible, communication needs should be addressed prior to admission, and patients and their families prepared for the unfamiliar world of the ICU.

Clinical review: Intensive care follow-up--what has it told us?

The majority of intensive care practitioners, until comparatively recently, was content to discharge surviving patients to the care of referring primary specialty colleagues who would undertake subsequent inpatient and outpatient care. With the exception of mortality statistics from clinical studies, the practitioners were thus denied the opportunity of understanding the full impact of critical illness on a patient and their family. The concept of the intensive care follow-up clinic has developed more recently, and is run commonly on multidisciplinary lines. These clinics serve a number of purposes, but importantly have drawn attention to broader patient-centred outcomes after intensive care. Investigators are just beginning to identify, and in some cases quantify, the postdischarge burden on patient and family; additional useful data have also come from follow-up of specific disease states. The purpose of the present review is to highlight some of the important issues that impact on recovery from critical illness towards an acceptable quality of postdischarge life. We have concentrated on the adult literature, and specifically on studies that inform us about the more general effects of critical illness. Head and spinal injury are thus largely ignored, as the effects of the primary injury overwhelm the effects of 'general' critical illness.

Commentary. Balancing sedation and analgesia in the critically ill

The authors have presented a template for a systematic approach to comforting critically ill patients that can be modified to suit institutional preferences. In this algorithm, the cause of patient discomfort is sought with the priority given to pain and then to anxiety. Special attention is directed to the identification of correctable causes of pain and anxiety with application of nonpharmacologic techniques or medications to control patient discomfort. This step is followed by subsequent reassessment of the need for sedation or anxiolysis and titration or discontinuation of therapy as able. The benefits of protocol-driven care are becoming increasingly evident, and the authors believe the algorithm outlined here provides a rational and practical approach to patient management. It also prompts the caregiver to reevaluate patients' needs and to keep to patients at target sedation levels. Doing so can promote cost effectiveness, reduce side effects caused by drugs, and decrease morbidity and ICU stay. Any treatment protocol or algorithm is simply a guide to therapy and cannot address every clinical situation. The importance of individualized care and physician or care team judgment must be emphasized.