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

Relatives' experiences of the transition from intensive care to home for acutely admitted intensive care patients-A qualitative study

BACKGROUND

Acute admission to an intensive care unit (ICU) can negatively affect quality of life for patients and their relatives. Relatives play an important caregiving role after the patient's admission. More knowledge and understanding of their needs are necessary as the patient transitions home.

AIM

This study aims to explore relatives' experiences of acutely admitted ICU patients' transition from the ICU to a general ward and then home.

STUDY DESIGN

A qualitative study with a phenomenological approach was conducted. Interviews were in-depth and featured open-ended questions. The interviews took place after the patients transitioned from ICU to home and were conducted online by videoconference. Data were analysed using Colaizzi's seven-step method.

RESULTS

Twelve relatives of acutely admitted ICU patients were interviewed. Five main themes emerged: (1) mixed feelings, (2) sense of not being involved, (3) limited information provision, (4) lack of acknowledgement as a caregiver, and (5) an uncertain future perspective. Relatives experience major uncertainties during transitions and prefer to be actively involved in care and care decisions.

CONCLUSIONS

This study indicates that relatives of ICU patients experience a lack of guidance during the transitions from the ICU to a general ward and to home, or a follow-up facility. More focus is needed on the themes of mixed feelings, the sense of not being involved, limited information provision, lack of acknowledgement as a caregiver, and an uncertain future perspective. This increased focus might improve the guidance during these transitions.

RELEVANCE TO CLINICAL PRACTICE

The insights from this study may help to improve the care of patients and their relatives during the transitions.

Lived Experiences of Patients on Hemodialysis Treatment at Kiruddu National Referral Hospital: A Phenomenological Study

Background

There is increasing number of patients undergoing hemodialysis globally. Patients on hemodialysis experience physical and emotional stress due to the changes brought by chronic kidney disease.

Aim

The study aimed at exploring the lived experiences of patients on hemodialysis treatment in Kiruddu National Referral Hospital.

Methods

The study employed a phenomenological design. Data was collected using audio tape recording of the interview from 9 participants selected through purposive sampling at Kiruddu National Referral Hospital. The thematic aspects of the lived experience were uncovered using Van Manen data analysis which included three approaches: the detailed or line-by-line approach, selective or highlighting approach and holistic approach.

Results

Six themes emerged during the analysis as hemodialysis prolongs survival; hemodialysis is indispensable, family financial support, physical limitations, emotional distress and adaptation.

Conclusion

It was concluded from the findings that the patients undergoing haemodialysis are facing a wide range of problems such as physical and emotional problems during the course of their treatment and think that haemodialysis is the only way of survival, and these problems need to be addressed. Understanding gained in this study can help nurses to utilize this information in improving the quality of nursing care and guide patients to provide positive reinforcement for their future living.

Patients' experiences of preparing for transfer from the intensive care unit to a hospital ward: A multicentre qualitative study

BACKGROUND

The transfer from an intensive care unit (ICU) to a regular ward often causes confusion and stress for patients and family members. However, little is known about the patients' perspective on preparing for the transfer.

AIM

The purpose of the study was to describe patients' experiences of preparing for transfer from an ICU to a ward.

STUDY DESIGN

Individual interviews with 14 former ICU patients from three urban hospitals in Stockholm, Sweden were conducted 3 months after hospital discharge. Qualitative content analysis was used to interpret the interview transcripts. Reporting followed the consolidated criteria for reporting qualitative research checklist.

RESULTS

The results showed that the three categories, the discharge decision, patient involvement, and practical preparations were central to the patients' experiences of preparing for the transition from the intensive care unit to the ward. The discharge decision was associated with a sense of relief, but also worry about what would happen on the ward. The patients felt that they were not involved in the decision about the discharge or the planning of their health care. To handle the situation, patients needed information about planned care and treatment. However, the information was often sparse, delivered from a clinician's perspective, and therefore not much help in preparing for transfer.

CONCLUSIONS

ICU patients experienced that they were neither involved in the process of forthcoming care nor adequately prepared for the transfer to the ward. Relevant and comprehensible information and sufficient time to prepare were needed to reduce stress and promote efficient recovery.

RELEVANCE TO CLINICAL PRACTICE

The study suggests that current transfer strategies are not optimal, and a more person-centred discharge procedure would be beneficial to support patients and family members in the transition from the ICU to the ward.

Patients' lived body experiences in the intensive care unit and beyond - a meta-ethnographic synthesis

INTRODUCTION

Physical therapists supporting patients in intensive care unit (ICU) rehabilitation can improve their clinical practice with insight in patients' lived body experiences.

OBJECTIVE

To gain insight in patients' lived body experiences during ICU stay and in recovery from critical illness.

METHODS

Through a comprehensive systematic literature search, 45 empirical phenomenological studies were identified. Patients' lived body experiences were extracted from these studies and synthesized following the seven-phase interpretative approach as described by Noblit and Hare.

RESULTS

Three lines of argument were illuminated: 1) "recovery from critical illness starts from a situation in which patients experience the lived body as unable;" 2) "patients experience progress in recovery from critical illness when the lived body is empowered;" and 3) "recovery from critical illness results in a lived body changed for life." Eleven third-order constructs were formulated as different kinds of bodies: 1) "an intolerable body;" 2) "an alienated body;" 3) "a powerless body;" 4) "a dependent body;" 5) "a restricted body;" 6) "a muted body;" 7) "a touched body;" 8) "a transforming body;" 9) "a re-discovering body;" 10) "an unhomelike body;" and 11) "a remembering body."

CONCLUSION

Patients' lived body experiences during ICU stay and in recovery from critical illness have richly been described in phenomenological studies and were synthesized in this meta-ethnography.

Exploring adult critical illness survivors' experiences of fatigue: A qualitative study

AIMS

To explore adult experiences of fatigue after discharge from an intensive care unit and identify potential management strategies.

DESIGN

An exploratory qualitative study.

METHODS

One to one audio-recorded semi-structured interviews with 17 adult survivors of critical illness in the United Kingdom, lasting up to 1 h, between September 2019 and January 2020. Anonymised and verbatim-transcribed interview data underwent a standard process of inductive thematic analysis as described by Braun and Clarke.

FINDINGS

Three themes were identified: fatigue is different for everyone; complex interrelating interactions; and personalised fatigue strategies. Fatigue was described as a distressing symptom, unique to the individual that causes an array of complex, often long-term interrelating impacts on the survivor and their wider family, made worse by a lack of understanding, empathy and support resources. Support from others, alongside interventions such as exercise, good nutrition, information and alternative therapies are used by survivors with variable degrees of success.

CONCLUSIONS

This qualitative study reports peoples' experiences of fatigue after critical illness. Findings highlight the significant impact it has on people's lives and those of their family and friends.

A phenomenological study on the experiences of patient transfer from the intensive care unit to general wards

Objectives

This study aimed to derive an in-depth understanding of the transfer experience of intensive care unit (ICU) patients in South Korea through a phenomenological analysis.

Methods

Participants were 15 adult patients who were admitted to a medical or surgical ICU at a university hospital for more than 48 hours before being transferred to a general ward. Data were collected three to five days after their transfer to the general ward from January to December 2017 through individual in-depth interviews and were analyzed using Colaizzi’s phenomenological data analysis method, phenomenological reduction, intersubjective reduction, and hermeneutic circle. Data analysis yielded eight themes and four theme clusters related to the unique experiences of domestic ICU patients in the process of transfer to the general ward.

Results

The four main themes of the patients’ transfer experiences were “hope amid despair,” “gratitude for being alive,” “recovery from suffering,” and “seeking a return to normality.”

Conclusion

Our findings expand the realistic and holistic understanding from the patient’s perspective. This study’s findings can contribute to the development of appropriate nursing interventions that can support preparation and adaptation to the transfer of ICU patients.

Prevalence and experience of fatigue in survivors of critical illness: a mixed-methods systematic review

We conducted a mixed methods systematic review to investigate the prevalence, experience and management of fatigue in survivors of critical illness. We identified 76 studies investigating fatigue or vitality in adults discharged from an intensive care unit and split the extracted data into three datasets: vitality scores from the Short Form Health Survey-36 (n = 54); other quantitative data (n = 19); and qualitative data (n = 9). We assessed methodological quality using critical appraisal skills programme tools. We adopted a segregated approach to mixed-methods synthesis. In a final step, we attributed combined results to one of four qualitative themes: prevalence and severity; contributing factors; impacts on quality of life; and assessment and management. Prevalence of fatigue ranged from 13.8 to 80.9%. Short Form Health Survey-36 vitality scores were commonly used as a marker of fatigue. Vitality scores reached a nadir approximately one month following ICU discharge (mean (SD) 56.44 (32.30); 95%CI 52.92-59.97). They improved over time but seldom reached reference population scores. Associated biological, disease-related and psychological factors included age, poor pre-morbid status, sleep and psychological disturbance. Qualitative data highlight the profound negative impact of fatigue on survivors' quality of life. Survivors seldom had any information provided on the potential impact of fatigue. No fatigue assessment tools specific to critical illness or evidence-based interventions were reported. Fatigue is highly prevalent in survivors of critical illness, and negatively impacts recovery. Further research on developing fatigue assessment tools specifically for critically ill patients and evaluating the impact of pharmacological and non-pharmacology interventions is needed.

Prevalence of delirium, depression, anxiety, and post-traumatic stress disorder among COVID-19 patients: protocol for a living systematic review

BACKGROUND

Previous studies on the impact of corona virus disease 2019 (COVID-19) on the mental health of the patients has been limited by the lack of relevant data. With the rapid and sustained growth of the publications on COVID-19 research, we will perform a living systematic review (LSR) to provide comprehensive and continuously updated data to explore the prevalence of delirium, depression, anxiety, and post-traumatic stress disorder (PTSD) among COVID-19 patients.

METHODS

We will perform a comprehensive search of the following databases: Cochrane Library, PubMed, Web of Science, EMBASE, and Chinese Biomedicine Literature to identify relevant studies. We will include peer-reviewed cross-sectional studies published in English and Chinese. Two reviewers will independently assess the methodological quality of included studies using the Joanna Briggs Institute Prevalence Critical Appraisal tool and perform data extraction. In the absence of clinical heterogeneity, the prevalence estimates with a 95% confidence interval (CI) of delirium, depression, anxiety, and post-traumatic stress disorder (PTSD) will be calculated by using random-effects model to minimize the effect of between-study heterogeneity separately. The literature searches will be updated every 3 months. We will perform meta-analysis if any new eligible studies or data are obtained. We will resubmit an updated review when there were relevant changes in the results, i.e., when outcomes became statistically significant (or not statistically significant anymore) or when heterogeneity became substantial (or not substantial anymore).

DISCUSSION

This LSR will provide an in-depth and up-to-date summary of whether the common neuropsychiatric conditions observed in patients hospitalized for severe acute respiratory syndrome (SARS-CoV) and Middle East respiratory syndrome (MERS) are also prevalent in a different stage of COVID-19 patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020196610.

Geriatric nurse involvement during intra-hospital transitions

Geriatric nurses are skilled in the special needs of hospitalized older adults. While significant focus has been placed on improving care transitions upon discharge, less attention has been placed on intra-hospital transitions. Intra-hospital transitions represent transfers occurring between hospital units or rooms. Intra-hospital transitions challenge normal nursing workflow and require careful consideration of care coordination to prevent adverse events for older adults. Frequent changes in environment and a lack of consistency in care may support the development or prolongation of delirium as older adults are transferred between units and rooms. Additional adverse event risks include infections and falls, which also increases with each transfer. Geriatric nurse involvement can enhance communication between units as well as ensuring appropriate geriatric assessments occur. Geriatric nurses are thus well positioned to act as leaders during intra-hospital transitions, potentially reducing these and adverse events.

Identifying patients' support needs following critical illness: a scoping review of the qualitative literature

BACKGROUND

Intensive care survivors suffer chronic and potentially life-changing physical, psychosocial and cognitive sequelae, and supporting recovery is an international priority. As survivors' transition from the intensive care unit to home, their support needs develop and change.

METHODS

In this scoping review, we categorised patients' support needs using House's Social Support Needs framework (informational, emotional, instrumental, appraisal) and mapped these against the Timing it Right framework reflecting the patient's transition from intensive care (event/diagnosis) to ward (stabilisation/preparation) and discharge home (implementation/adaptation). We searched electronic databases from 2000 to 2017 for qualitative research studies reporting adult critical care survivors' experiences of care. Two reviewers independently screened, extracted and coded data. Data were analysed using a thematic framework approach.

RESULTS

From 3035 references, we included 32 studies involving 702 patients. Studies were conducted in UK and Europe (n = 17, 53%), Canada and the USA (n = 6, 19%), Australasia (n = 6, 19%), Hong Kong (n = 1, 3%), Jordan (n = 1, 3%) and multi-country (n = 1, 3%). Across the recovery trajectory, informational, emotional, instrumental, appraisal and spiritual support needs were evident, and the nature and intensity of need differed when mapped against the Timing it Right framework. Informational needs changed from needing basic facts about admission, to detail about progress and treatments and coping with long-term sequelae. The nature of emotional needs changed from needing to cope with confusion, anxiety and comfort, to a need for security and family presence, coping with flashbacks, and needing counselling and community support. Early instrumental needs ranged from managing sleep, fatigue, pain and needing nursing care and transitioned to needing physical and cognitive ability support, strength training and personal hygiene; and at home, regaining independence, strength and return to work. Appraisal needs related to obtaining feedback on progress, and after discharge, needing reassurance from others who had been through the ICU experience.

CONCLUSIONS

This review is the first to identify the change in social support needs among intensive care survivors as they transition from intensive care to the home environment. An understanding of needs at different transition periods would help inform health service provision and support for survivors.

Protocol for a mixed-methods exploratory investigation of care following intensive care discharge: the REFLECT study

INTRODUCTION

A substantial number of patients discharged from intensive care units (ICUs) subsequently die without leaving hospital. It is unclear how many of these deaths are preventable. Ward-based management following discharge from ICU is an area that patients and healthcare staff are concerned about. The primary aim of REFLECT (Recovery Following Intensive Care Treatment) is to develop an intervention plan to reduce in-hospital mortality rates in patients who have been discharged from ICU.

METHODS AND ANALYSIS

REFLECT is a multicentre mixed-methods exploratory study examining ward care delivery to adult patients discharged from ICU. The study will be made up of four substudies. Medical notes of patients who were discharged from ICU and subsequently died will be examined using a retrospective case records review (RCRR) technique. Patients and their relatives will be interviewed about their post-ICU care, including relatives of patients who died in hospital following ICU discharge. Staff involved in the care of patients post-ICU discharge will be interviewed about the care of this patient group. The medical records of patients who survived their post-ICU stay will also be reviewed using the RCRR technique. The analyses of the substudies will be both descriptive and use a modified grounded theory approach to identify emerging themes. The evidence generated in these four substudies will form the basis of the intervention development, which will take place through stakeholder and clinical expert meetings.

ETHICS AND DISSEMINATION

Ethical approval has been obtained through the Wales Research and Ethics Committee 4 (17/WA/0107). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.

TRIAL REGISTRATION NUMBER

ISRCTN14658054.

Patient transfer from the intensive care unit to a general ward

The transfer of patients from the intensive care unit (ICU) to a general ward can present several challenges for nurses. Such patients are at high risk of adverse outcomes, including readmission to the ICU, and increased nosocomial infections and mortality, with a resultant increase in hospital costs. This article explores the challenges of transferring patients from the ICU and uses evidence to examine ways to address them to ensure optimal care for a complex patient group. Transfer time, factors affecting general ward care, handover processes, recognition of deterioration and education, intensive care outreach, and the psychological factors affecting these patients are examined.

Elucidating the information exchange during interfacility care transitions: Insights from a Qualitative Study

OBJECTIVE

To explore the perceptions of patients, their caregivers and healthcare professionals associated with the exchange of information during transitioning from two acute care hospitals to one rehabilitation hospital.

DESIGN

An exploratory qualitative study using semi-structured interviews and observation.

PARTICIPANTS AND SETTING

Patients over the age of 65 years admitted to an orthopaedic unit for a non-elective admission, their caregivers and healthcare professionals involved in their care. Participating sites included orthopaedic inpatient units from two acute care teaching hospitals and one orthopaedic unit at a rehabilitation hospital in an urban setting.

FINDINGS

Three distinct themes emerged from participants' narrative of their transitional care experience: (1) having no clue what the care plan is, (2) being told and notified about the plan and (3) experiencing challenges absorbing information. Participating patients and their caregivers reported not being engaged in an active discussion with healthcare professionals about their care transition plan. Several healthcare professionals described withholding information within the plan until they themselves were clear about the transition outcomes.

CONCLUSION

This study highlights the need to increase efforts to ensure that effective information exchanges occur during transition from acute care hospital to rehabilitation settings.

Nurses' experience of the transfer of ICU patients to general wards: A great responsibility and a huge challenge

AIMS AND OBJECTIVES

The aim of the study was to describe nurses' experiences of patients' transition from ICUs to general wards and their suggestions for improvements.

BACKGROUND

In the ICU, the most seriously ill patients with life-threatening conditions and multiple organ dysfunction syndromes are cared for and carefully monitored by specially trained professionals using advanced techniques for the prevention of failure of vital functions. The transfer of ICU patients to general wards means a change from a high to a lower level, including the loss of one-to-one nursing and a reduction of visible monitoring equipment and general close attention.

DESIGN

A qualitative descriptive design.

METHODS

Eight nurses from three different inpatient units in Norway, five from a university hospital and three from a local hospital were selected through a convenience sample. Interviews with open questions were conducted, and qualitative content analysis was used to explore the data.

RESULTS

Nurses' experiences were described in one main category: ICU patients' transition-a great responsibility and a huge challenge, and two generic categories: (i) a challenging transition for nurses, patients and relatives and (ii) dialogue and competencies as tools for improvement, with six subcategories.

CONCLUSION

A number of factors affected patient care, such as poor cooperation, communication, reporting, expertise and clinical gaze. It was clear that the general wards had major challenges, and a number of improvements were suggested.

RELEVANCE TO CLINICAL PRACTICE

This study shows that there is still a gap between the ICU and general wards and that nurses continue to struggle with this. It is therefore important that the managers responsible for the quality of care together with the professionals take seriously the criticism in the present and previous studies and work towards a safe transition for patients.

Sleep after critical illness: Study of survivors of acute respiratory distress syndrome and systematic review of literature

Background and Aims:

This study aims to evaluate the sleep quality, architecture, sleep-related quality of life, and sleep-disordered breathing (SDB) in acute respiratory distress syndrome (ARDS) survivors early after discharge.

Materials and Methods:

In this prospective, observational study, consecutive patients with ARDS discharged from the Intensive Care Unit (ICU) underwent evaluation with Epworth sleepiness scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Functional Outcomes of Sleep Questionnaire (FOSQ), and overnight polysomnography. Patients having one or more of the following characteristics were classified as having abnormal sleep: ESS>10, PSQI>5, FOSQ <17.9, apnea–hypopnea index (AHI) ≥5, or AHI during rapid eye movement (REM) sleep ≥5.

Results:

Twenty patients (median interquartile range [IQR] age of 24 [22–28] years, 11 [55%] females) were included in the study. Acute febrile illness of unknown etiology with multi-organ dysfunction syndrome was the most common underlying etiology for ARDS. The median (IQR) PaO₂/FiO₂ ratio and APACHE II scores on admission were 176 (151–191.5) and 14 (14–16), respectively. The median (IQR) duration of stay in the ICU was 10 days (7.3–19.5). The overall sleep efficiency (median [IQR], 54% [32.3–65.4%]) was poor. None of the patients had ESS>10, seven (35%) had global PSQI>5 and one had FOSQ <17.9. Ten (50%) patients had at least one characteristic that suggested abnormal sleep (4 insomnia, 2 central sleep apnea, 1 obstructive sleep apnea, 1 REM-SDB, and 2 with a high PSQI, but no specific sleep abnormality).

Conclusions:

Sleep disturbances are common in ARDS survivors early after discharge from the ICU.

Physical and Mental Health of Patients Immediately After Discharge From Intensive Care Unit and 24 Hours Later

Background:

Monitoring the health status of patients discharged from intensive care units is a crucial method of service evaluation.

Objectives:

This study aimed to assess the physical and mental health status of patients immediately after discharge from the ICU and 24 hours later.

Patients and Methods:

This descriptive comparative study was conducted on 104 patients discharged from the ICUs of a referral trauma center in Shiraz, Southwest Iran. Physical parameters, including respiratory rate, need for supplemental oxygen, heart rate, blood pressure, and need for cardiac monitoring, were assessed. Hospital anxiety and depression scale (HADS) was used for mental health evaluation. The mental and physical status of patients were assessed before ICU discharge and 24 hours later; data were recorded in information forms and were analyzed using SPSS statistical software version 17.

Results:

At the time of discharge, the respiratory rate of 28% of the participants was more than 24 minutes, and 95.2% received supplemental oxygen. However, after 24 hours these values decreased to 10% and 21.6%, respectively. The mean heart rate and systolic blood pressure were within the normal range at both time points. Additionally, 63% of the patients had anxiety scores above 11 at both time points, reflecting high anxiety. The number of patients who reported depression increased from 58.7% at ICU discharge to 69.6% after 24 hours.

Conclusions:

Despite the considerable improvement in most of the patients’ physical condition in the first 24 hours after discharge from ICU, a significant number of them remain at risk for the development of adverse effects from this transition. The high prevalence of mental health disorders in these patients reveals the necessity to conduct follow-up consultations.

Critical illness trajectory for patients, families and nurses - a literature review

BACKGROUND

In the 21st century, we are starting to discover and understand the longer term sequelae of critical illness from both patient's and family members' perspectives. The consequential effects on physical and psychological function and the social landscape are being slowing realized. We are beginning to understand the long-term legacy of critical care, with survivorship possibly the greatest challenge within the critical care setting.

AIM

To draw together research that has appraised the experience of surviving critical illness from the holistic, triadic perspectives of survivor, relative and critical care nurse. In doing so, knowledge of the complexities of the critical care trajectory is enhanced.

SEARCH STRATEGY

Using Medline; Assia; CINAHL Plus; SCOPUS; Web of knowledge searches from 2000 to 2015 were conducted utilizing the terms 'critical care'; 'intensive care', ITU; patient*; relative*; family member*; experience*; nurse*, and trajectory. Relevant exclusion criteria were applied to provide a generalist adult critical care perspective.

RESULTS

Following a process of constant comparative analysis of the literature and thematic synthesis, seven themes were highlighted. Facing mortality, critical junctures, physiological sequelae, psychological sequelae, family presence, beyond meeting the needs of family members and technology versus humanity were all emergent themes.

CONCLUSION

As humans, we do not live an isolated life; we are interdependent upon each other. This inclusive review of literature has highlighted the lacunae and areas of dissonance both in the literature and in clinical practice in relation to the critical care trajectory as experienced by survivors of critical illness and their families.

RELEVANCE TO CLINICAL PRACTICE

Critical care nurses can and should play a role in preparing and supporting patients and families beyond the critical care unit. In turn, Registered Nurses needed to be supported to fulfil this important role in enabling the process of moving patients and their families from surviving to thriving (survivorship).

Jordanian survivors' experiences of recovery from critical illness: a qualitative study

BACKGROUND

Despite the fact that a lot of patients consider their discharge from hospitals as a positive sign of progress towards regained health, many of them start suffering from physical, psychological and social problems after discharge from intensive care units.

AIM

This study aims to describe the experiences of Jordanian survivors of critical illnesses 3 months after discharge from a hospital intensive care unit.

METHODS

A descriptive qualitative approach was used to involve 18 Jordanian patients from two hospitals in a major Jordanian city using open-ended interviews. Interview transcripts were analysed using content analysis method.

RESULTS

Three main themes have emerged from the data: (1) new meaning of life; (2) different perspectives on the meaning of life, and (3) struggle for role identity.

LIMITATION

The sample was chosen from one city in Jordan; longitudinal study might help identify the change in patients' experiences over time.

CONCLUSION

Patients described the discharge from the intensive care unit as a means of rescue from death; they began to value their spiritual and religious rituals. Negative traumatic experiences hindered the patients' recovery process. During recovery, patients struggled to resume their power and role in family.

IMPLICATIONS FOR NURSES AND HEALTH POLICY

This study emphasizes the importance of providing care according to the patient's individual needs, related to their cultural and spiritual milieu; there is a need to develop follow-up services for ICU survivors within a national health policy. Further educational and training programmes in the patient's issues after discharge from hospital are needed. This will definitely help nurses care after this patient group.

Transfer out of intensive care: an evidence-based literature review

Critical care beds are a finite resource. Transfer or discharge of patients from the intensive care unit affects the flow of patients in critical care. Effective whole hospital bed management is key to the successful management of the critical care service. However, admission to the critical care unit alone can be extremely frightening, distressing, and traumatic not only for the patients but their families as well. Although transfer to the medical floors is a positive step toward physical recovery, it can be equally traumatic, and many patients and their families exhibit stress, fear, and anxiety. The purpose of this article was to systematically review the effects of intensive care unit transfer or discharge to medical-surgical floors on adult critically ill patients, their family members and nurses.

Sleep disturbance in older ICU patients

Maintaining a stable and adequate sleeping pattern is associated with good health and disease prevention. As a restorative process, sleep is important for supporting immune function and aiding the body in healing and recovery. Aging is associated with characteristic changes to sleep quantity and quality, which make it more difficult to adjust sleep–wake rhythms to changing environmental conditions. Sleep disturbance and abnormal sleep–wake cycles are commonly reported in seriously ill older patients in the intensive care unit (ICU). A combination of intrinsic and extrinsic factors appears to contribute to these disruptions. Little is known regarding the effect that sleep disturbance has on health status in the oldest of old (80+), a group, who with diminishing physiological reserve and increasing prevalence of frailty, is at a greater risk of adverse health outcomes, such as cognitive decline and mortality. Here we review how sleep is altered in the ICU, with particular attention to older patients, especially those aged ≥80 years. Further work is required to understand what impact sleep disturbance has on frailty levels and poor outcomes in older critically ill patients.

Organizing safe transitions from intensive care

Background. Organizing and performing patient transfers in the continuum of care is part of the work of nurses and other staff of a multiprofessional healthcare team. An understanding of discharge practices is needed in order to ultimate patients' transfers from high technological intensive care units (ICU) to general wards. Aim. To describe, as experienced by intensive care and general ward staff, what strategies could be used when organizing patient's care before, during, and after transfer from intensive care. Method. Interviews of 15 participants were conducted, audio-taped, transcribed verbatim, and analyzed using qualitative content analysis. Results. The results showed that the categories secure, encourage, and collaborate are strategies used in the three phases of the ICU transitional care process. The main category; a safe, interactive rehabilitation process, illustrated how all strategies were characterized by an intention to create and maintain safety during the process. A three-way interaction was described: between staff and patient/families, between team members and involved units, and between patient/family and environment. Discussion/Conclusions. The findings highlight that ICU transitional care implies critical care rehabilitation. Discharge procedures need to be safe and structured and involve collaboration, encouraging support, optimal timing, early mobilization, and a multidiscipline approach.

Does time of transfer from critical care to the general wards affect anxiety? A pragmatic prospective cohort study

OBJECTIVES

To examine prospectively the impact of transfer time on patient anxiety.

DESIGN

A pragmatic prospective cohort study.

SETTING

14 bed adult intensive care unit (ICU) in a National Health Service teaching hospital trust in the United Kingdom.

METHODS

Critically ill patients staying on the ICU for at least 24 hours and clinically ready for transfer to the general ward completed the Hospital Anxiety and Depression Scale questionnaire (Zigmond and Snaith, 1983) at: pre-transfer - on the critical care (when they were clinically ready for transfer to the general ward), post-transfer - on the general ward.

RESULTS

The post-transfer median (range) score for anxiety was 6 (4-10) for day time and higher at 12.5 (9-16) for night time; this was found to be statistically significant U=80, p=0.011, r=0.37 and the post-transfer incidence of anxiety cases was 22% (8/36) for day time and higher at 64% (7/11) for night time; this was found to be statistically significant U=91, p=0.007, r=0.39.

CONCLUSION

This study suggests that transfers at night time are more anxiety provoking for patients than transfers in the day time.

Intensive care survivors' experiences of ward-based care: Meleis' theory of nursing transitions and role development among critical care outreach services

AIMS AND OBJECTIVES

To explore the psychosocial needs of patients discharged from intensive care, the extent to which they are captured using existing theory on transitions in care and the potential role development of critical care outreach, follow-up and liaison services.

BACKGROUND

Intensive care patients are at an increased risk of adverse events, deterioration or death following ward transfer. Nurse-led critical care outreach, follow-up or liaison services have been adopted internationally to prevent these potentially avoidable sequelae. The need to provide patients with psychosocial support during the transition to ward-based care has also been identified, but the evidence base for role development is currently limited.

DESIGN AND METHODS

Twenty participants were invited to discuss their experiences of ward-based care as part of a broader study on recovery following prolonged critical illness. Psychosocial distress was a prominent feature of their accounts, prompting secondary data analysis using Meleis et al.'s mid-range theory on experiencing transitions.

RESULTS

Participants described a sense of disconnection in relation to profound debilitation and dependency and were often distressed by a perceived lack of understanding, indifference or insensitivity among ward staff to their basic care needs. Negotiating the transition between dependence and independence was identified as a significant source of distress following ward transfer. Participants varied in the extent to which they were able to express their needs and negotiate recovery within professionally mediated boundaries.

CONCLUSION

These data provide new insights into the putative origins of the psychosocial distress that patients experience following ward transfer.

RELEVANCE TO CLINICAL PRACTICE

Meleis et al.'s work has resonance in terms of explicating intensive care patients' experiences of psychosocial distress throughout the transition to general ward-based care, such that the future role development of critical care outreach, follow-up and liaison services may be more theoretically informed.

National Survey of Rehabilitation after Critical Illness

This paper reports the results of a survey of compliance with the National Institute of Health and Clinical Excellence (NICE) clinical guideline 83 (CG83) Rehabilitation after Critical Illness1 in NHS hospitals in England. A data collection tool, structured around the detailed recommendations, was distributed throughout the 28 critical care networks in England. Usable data were returned from 59 intensive care units. The overall results show that 52% of units are fully compliant with rehabilitation guidelines for patients within the ICU. This decreases to 48% prior to discharge to the ward. Further reduction in compliance is then seen during the ward stay (27%), prior to discharge from hospital (33%) and at 2–3 months following discharge from intensive care (31%). There are health inequalities in this area that are proving challenging to overcome. Further evidence of the best way to deliver rehabilitation and its long-term health and economic benefits is required.

Patients' and relatives' experiences of transfer from intensive care unit to wards

AIMS

This literature review looks at the evidence around transferring patients from intensive care units (ICU) to wards. The literature informs us that patients and their families experience problems when being transferred from an ICU environment and that this increases overall anxiety.

BACKGROUND

The effects of surviving critical illness often have a profound psychological impact on patients and families This study examines the experiences of adult patients, and their families, following their transfer from the ICU to the ward.

FINDINGS

Five themes emerged from this literature review: physical responses, psychological responses, information and communication, safety and security, and the needs of relatives.

CONCLUSIONS

This review reminds us that these problems can be reduced if information and communication around time of transfers were improved.

RELEVANCE TO CLINICAL PRACTICE

As critical care nurses it is essential that we prepare patients and families for transfer to wards.

Patients' transition in the intensive care units: concept analysis

BACKGROUND

Adequate preparation of critically ill patients throughout their transition experience within and following discharge from the Intensive Care Unit is an important element of the nursing care process during critical illness. However, little is known about nurses' perspectives of, and engagement in, caring for critically ill patients during their transition experiences.

AIM

This paper aims to review the literature about the concept of transition within the context of critically ill patients in the Intensive Care Unit, focusing on Intensive Care Unit nurses.

REVIEW METHOD

CINAHL, MEDLINE, OVID, Science Direct, SAGE eReference and SAGE Journal Online data bases were searched for relevant literature published since 1970.

RESULTS

The critically ill patients' transitions in Intensive Care Units are generally described as a period of transfer or change of situation, or the experience of inner change or role during and after the illness. The critically ill patients' transition experience per se is not directly described, nor is nurses' understanding of it.

CONCLUSION

Nurses' understanding of critically ill patients' transition may significantly impact the patients' care in the Intensive Care Unit. Thus, research is needed that focuses more on evaluating nurses' understanding of patients' transition and its consequences.

Identifying intensive care unit discharge planning tools: protocol for a scoping review

BACKGROUND

Transitions of care between providers are vulnerable periods in healthcare delivery that expose patients to preventable errors and adverse events. Patient discharge from the intensive care unit (ICU) to a medical or surgical hospital ward is one of the most challenging and high risk transitions of care. Approximately 1 in 12 patients discharged will be readmitted to ICU or die before leaving the hospital. Many more patients are exposed to unnecessary healthcare, adverse events and/or are disappointed with the quality of their care. Our objective is to conduct a scoping review by systematically searching the literature to identify ICU discharge planning tools and their supporting evidence-base including barriers and facilitators to their use.

METHODS AND ANALYSIS

Systematic searching of the published health literature will be conducted to identify the existing ICU discharge planning tools and supporting evidence. Literature (research and non-research) reporting on the tools used to facilitate decision making and/or communication at ICU discharge with patients of any age will be included. Outcomes will include adverse events and provider and patient/family-reported outcomes. Two investigators will independently review the abstracts (screen 1) to identify those meeting the inclusion criteria and then independently assess the full text articles (screen 2) to determine if they meet the inclusion criteria. Data collection will include information on citations and identified tools. A quality assessment will be performed on original research studies. A descriptive summary will be developed for each tool.

ETHICS AND DISSEMINATION

Our scoping review will synthesise the literature for ICU discharge planning tools and identify the opportunities for knowledge to action and gaps in evidence where primary evidence is necessary. This will serve as the foundational element in a multistep research programme to standardise and improve the quality of care provided to patients during ICU discharge. Ethics approval is not required for this study.

[The transition process from the intensive care unit to the ward: a review of the literature]

The optimum transition process from the ICU to the ward is key to avoiding the appearance of anxiety in the patient and family, increase of re-admissions in the ICU with the consequent increase in costs and jeopardization to the patient's safety.

OBJECTIVE

1) To identify, study and give a critical presentation of the existing evidence on how patients, families and nurses experience the transition from ICU to the ward; 2) to analyze the possible interventions available for the development of an optimum transition process.

METHODOLOGY

A review was made of the evidence available in the main databases. In addition, several journals specialized in Intensive Care were reviewed. Studies with a qualitative, quantitative or mixed approach and reviews on the subject with a systematic methodology or narrative reviews were included.

RESULTS

A total of 23 papers were selected for review, 10 of which were qualitative studies, 11 quantitative and two had combined methodology. «Transfer anxiety» was identified after the analysis of these articles as one of the recurring aspects. Discrepancies regarding who should take responsibility for the preparation of the transition process and when it should be performed were also found. In the literature reviewed, several interventions have been proposed to facilitate an optimal transition process such as developing information brochures, creating a profile of practicing nursing liaison between the ICU and the ward and ICU discharge report.

CONCLUSIONS

This review emphasizes the importance of taking into account the perspectives of patients, families and nurses to perform optimal planning of the transition of the patient from the ICU to the ward to ensure their safety.

Burn patients' experience of pain management: a qualitative study

Pain is a major problem after burns and researchers continue to report that pain from burns remains undertreated. The inadequate pain control results in adverse sequalae physically and psychologically in the burn victims. A better understanding of a burn patient's experience is important in identifying the factors responsible for undertreated pain and establishing effective pain management guidelines or recommendation in the practice of pain relief for burn injuries. This study sought to explore and describe the experience that patients have about pain related to burn-injury during hospitalization. Semi-structured interviews were conducted on eight patients with moderate to severe pain from burn injuries recruited from a Burn Centre in Northwest China. Data was collected by in-depth interviews and qualitative description after full transcription of each interview. Analysis involved the identification of themes and the development of a taxonomy of patients' experience of burn pain and its management. Three themes were indentified: (1) patients' experience of pain control, (2) patients' perception on burn pain management, and (3) patients' expectation of burn pain management. Findings from this study suggested that patients experience uncontrolled pain both physically and psychologically which may serve as an alert for awareness of health professionals to recognize and establish a multidisciplinary pain management team for burn victims, including surgeons, critical care specialists, anesthesiologists, nurses, psychologists, and social workers to accomplish safe and effective strategies for pain control to reach an optimal level of pain management in burn patients. It also provides insights and suggestions for future research directions to address this significant clinical problem.

Effect of attachment styles of individuals discharged from an intensive care unit on intensive care experience

INTRODUCTION

The present study was conducted as a cross-sectional type to examine the effect of attachment styles of individuals discharged from an intensive care unit (ICU) on intensive care experience and health status.

METHODS

The population of the study included patients discharged from the ICU in a university hospital. The sample included 108 patients who were selected via simple random sampling method. Data were collected using a Demographic Information Questionnaire, Intensive Care Experience Questionnaire, the Relationship Scales Questionnaire, and Acute Physiology and Chronic Health Evaluation II system. In the analysis of data, frequency, percentage, mean, standard deviation, minimum and maximum values, and Mann-Whitney U, Kruskal-Wallis, Bonferroni-adjusted Mann-Whitney, and Spearman ρ correlation tests were used.

RESULTS

A significant difference in the awareness of surroundings subscale for attachment styles was noted (χ(2) = 10.820, P ≤ .01). Moreover, participants' attachment styles (fearful, preoccupied, and dismissing) and intensive care experience were significantly correlated. A significant correlation was found between participants' secure attachment style points and Acute Physiology and Chronic Health Evaluation II score during discharge from the ICU (r = 0.322, P = .001).

CONCLUSION

Individuals' attachment styles should be taken into consideration when planning and implementing the nursing care and treatment of individuals hospitalized in an ICU.

[Factors influencing relocation stress syndrome in patients following transfer from intensive care units]

PURPOSE

The purpose of this study was to identify the levels of relocation stress syndrome (RSS) and influencing the stress experienced by Intensive Care Unit (ICU) patients just after transfer to general wards.

METHODS

A cross-sectional study was conducted with 257 patients who transferred from the intensive care unit. Data were collected through self-report questionnaires from May to October, 2009. Data were analyzed using the Pearson correlation coefficient, t-test, one-way ANOVA, and stepwise multiple linear regression with SPSS/WIN 12.0.

RESULTS

The mean score for RSS was 17.80+/-9.16. The factors predicting relocation stress syndrome were symptom experience, differences in scope and quality of care provided by ICU and ward nursing staffs, satisfaction with transfer process, length of stay in ICU and economic status, and these factors explained 40% of relocation stress syndrome (F=31.61, p<.001).

CONCLUSION

By understanding the stress experienced by ICU patients, nurses are better able to provide psychological support and thus more holistic care to critically ill patients. Further research is needed to consider the impact of relocation stress syndrome on patients' health outcomes in the recovery trajectory.

Muslim women's experiences of suffering in Jordanian intensive care units: a narrative study

This paper explores Muslim women's experiences of suffering in Jordanian intensive care units. A narrative approach was employed to access women's stories of their critical illness. Sixteen women who had spent at least 48 hours in intensive care were recruited from two hospitals in a Jordanian city and took part in between one and three interviews over a six-month period. Women's accounts of suffering were pervaded with physical, social, spiritual and technological themes. Pain was a central strand in the women's accounts and was experienced often as severe, overwhelming and disturbing to their sleep. The sudden onset of illness, the unfamiliar ICU environment and feeling of uncertainty made it difficult for the women to interpret their experiences. Religious beliefs and cultural norms helped the women make sense of their suffering. Social support, especially from the family, was reported by the women to be essential: a lack of social support was seen as a symbol of death. This study emphasises the importance of looking at a patient who is critically ill as a whole person within the context of their cultural, spiritual and biographical milieu.

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.

More than nothing: the lived experience of tracheostomy while acutely ill

While the physical sensations surrounding tracheostomy tube insertion have been reported within nursing and allied healthcare literature, the lived experience of these sensations is poorly described. This appears relevant given the imminent results of the Tracman study (2008). A purposive sample of three participants who had tracheostomy tubes previously within a critical care area or still in situ were recruited. They described their experiences in a face-to-face semi-structured interview that were audio taped. The interviews were transcribed verbatim and analysed using Giorgi's 5 concrete steps of the human scientific phenomenological method (1997). Findings revealed themes that drew attention to the fundamental aspects of the experience. These were: Practical recommendations draw attention to the organisational support required for staff expected to care for these patients in the ward environment. This involves the introduction of evidence based guidelines and competency based care to promote the acquisition of skills required to perform those essential tasks such as suction and stoma care to a high standard. Protected, formalised skills based teaching is seen as fundamental in this process. Patients' felt confident in nursing staff that were able to demonstrate proficiency with such tasks and this is seen as crucial when one considers that the tracheostomy tube is a new experience for patients.

Struggle with a gap between intensive care units and general wards

Nursing critically ill patients includes planning and performing safe discharges from Intensive Care Units (ICU) to the general wards. The aim of this study was to obtain a deeper understanding of the main concern in the ICU transitional process-the care before, during, and after the transfer of ICU patients. Interviews were conducted with 35 Swedish nurses and analysed according to grounded theory. The main concern was the nurses' "struggling with a gap." The "gap" was caused by differences in the altered level of care and contributed to difficulties for nurses encountering an overlap during the transitional care. The categories: sheltering, seeking organizational intertwining and striving for control are related to the core category and were used to generate a theory. The nurses sought improved collaboration, and employed patient-centred routines. They wanted access to necessary tools; they relayed or questioned their own competence and sought assurance of the patients' ability to be transferred. If the nurses felt a loss of control, lack of intertwining and lack of collaboration, they sheltered their patients and themselves. Intertwining was more difficult to perform, but actually even more important to do. With knowledge about ICU transitional care, collaboration, routines, and with an organization that provides an educational environment, the process could be improved.

Experiences of intensive care unit diaries: 'touching a tender wound'

AIM

The aim of this study was to describe peoples' experiences of a personal diary written when they were critically ill and receiving care in an intensive care unit (ICU).

BACKGROUND

In some ICUs, diaries are written by the ICU staff and close relatives of those who are critically ill and mechanically ventilated, but there is a lack of studies that focus on the experiences of the formerly critically ill of personal diaries written when in an ICU.

METHODS

Qualitative personal interviews were conducted with nine people who were formerly critically ill. The interview texts were analysed using qualitative content analysis.

FINDINGS

From the analysis of the data, one theme emerged - touching a tender wound, with four categories: being afraid and being deeply touched, appreciating close relatives' notes, a feeling of unreality and gaining coherence. The participants were deeply touched when they read the diary for the first time. Parts of it were experienced as unreal, as if they were reading about someone else. The diary provided necessary knowledge about what had happened during the time when the participants were critically ill and from which they had only fragmented or no memories at all. Even though it aroused strong feelings, reading the diary was experienced as an important support for a long time after their stay in the ICU. Experiencing that one was not fully aware of what had happened and then reading about oneself being critically ill and about one's close relatives' experiences was interpreted as touching a tender wound.

CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE

It is suggested that a diary may be a tool that can help formerly critically ill people to gain a sense of coherence concerning their critical illness experience, but reading it can be painful and demanding.

Memories of being injured and patients' care trajectory after physical trauma

Background

The purpose of this study was to acquire a deeper understanding of patients' memories of being injured and the trajectory of care before, during and after their Intensive Care Unit (ICU) stay.

Methods

Interviews were conducted with eighteen informants who after physical trauma had been cared for in the ICU. The interviews were analyzed by using a phenomenological hermeneutical method.

Results

The memories of injury during the trajectory of care are illustrated in a figure in which the injured informants have memories from five scenes; the scene of the accident, emergency unit, ICU, nursing ward and of coming home. Twelve subthemes were abstracted and four themes emerged; a surrealistic world, an injured body, care, and gratitude for life. After the accident, a "surrealistic world" appeared along with bad memories of being in a floating existence where plans had to be changed. This world was unfamiliar, sometimes including delusional and fragmentary memories from the ICU, and it was experienced as uncontrollable. They felt connected to an "injured body", experiencing bad memories from the ICU of being injured, from the nursing ward of simply enduring and of being in a No Man's Land when coming home; their lives had become limited. At the same time they were "connected to care" with good memories of receiving attention from others at the scene of the accident, being taken cared of at the emergency unit and cared for in the ICU. This care made them realise that people are responsible for each other, and they felt comforted but also vulnerable. Finally, they experienced "gratitude for life". This included good memories of being loved together with support from their families at the ICU, wanting to win life back at the nursing ward and acceptance when returning home. The support from their families made them realise that they fit in just as they are.

Conclusion

When bad memories of a surrealistic world and of being injured are balanced by good ones of care and love with a gratitude for life, there are more possibilities to move on despite an uncertain future following the injury.

Critical care illness and rehabilitation

Critical care illness is often followed by protracted, slow and incomplete recovery. Survivors given access to specialized rehabilitation achieve a higher level of recovery, with greater independence and less need for social or health-care support long-term.

'One patient amongst many': a qualitative analysis of intensive care unit patients' experiences of transferring to the general ward

Introduction

Many patients experience 'relocation stress' when they are transferred from an intensive care unit (ICU) to step-down (high dependency) or general ward care, and much has been written about the psychological causes. This qualitative analysis of in-depth, narrative interviews with former ICU patients explores and examines patients' accounts in order to identify additional causes of relocation stress.

Methods

Forty former ICU patients were recruited throughout the UK, using maximum variation sampling, to achieve a broad range of experiences of intensive care. Interviews in people's homes were recorded on video and audio equipment as part of a study for the Database of Personal Experiences of Health and Illness (DIPEx) web resource. All interviews were transcribed, checked and returned to respondents. For this report, a qualitative thematic analysis was used to explore experiences of transfer.

Results

We found that most people experienced relocation distress not only because of physical and emotional difficulties relating to their illness and treatment and the inevitable anxiety resulting from leaving a protected environment, but also from concrete, practical causes. These included specific concerns about communication, feeding, nursing care and support, as well as ward organization and environment. Written excerpts from the interviews and two video excerpts taken from the DIPEx website illustrate our findings.

Conclusion

We conclude that there are several aspects of care that deserve further examination by researchers and service providers, and that not all of the factors associated with relocation stress should be seen as an inevitable consequence of the psychological adjustment involved in transfer from an ICU.