Re-building life after ICU: a qualitative study of the patients' perspective

The Experience of Physical Recovery and Physical Rehabilitation Following Hospital Discharge for Intensive Care Survivors-A Qualitative Systematic Review

BACKGROUND

Over 120,000 people in the UK survive critical illness each year, with over 60% of these experiencing mobility issues and reduced health-related quality of life after discharge home. This qualitative systematic review aimed to explore critical care survivors' perceptions, opinions, and experiences of physical recovery and physical rehabilitation following hospital discharge.

METHODS

This review followed the Joanna Briggs Institute (JBI) methodology with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and was conducted between January 2020 and June 2022. The search was conducted using the following databases: Embase, CINAHL, Medline Ovid, Cochrane, and the Joanna Briggs Institute, and sources of grey literature were searched for eligible studies. Qualitative studies focused on physical rehabilitation or recovery, involving adult survivors of critical illness who had been discharged from hospital.

RESULTS

A total of 7 of 548 identified studies published in 2007-2019 were eligible for inclusion. The findings indicate that qualitative evidence around the experiences of physical recovery and rehabilitation interventions following discharge home after critical illness is limited. Three synthesised findings were identified: 'Positivity, motivation and hope'; 'Recovery is hard and patients need support'; and 'Patients experience challenges in momentum of physical recovery'.

CONCLUSIONS

Survivors struggle to access healthcare professionals and services following discharge home, which influences the momentum of physical recovery. Supervised exercise programmes had a positive impact on the perception of recovery and motivation. However, 'simple' structured exercise provision will not address the range of challenges experienced by ICU survivors. Whilst some factors influencing physical recovery are similar to other groups, there are unique issues experienced by those returning home after critical illness. Further research is needed to identify the support or interventions survivors feel would meet their needs and assist their physical recovery. This study was prospectively registered with Prospero on 3/2/2020 with registration number CRD42020165290.

An Intensive Care Unit peer support group: Participants' views on format, content and the impact on recovery journeys

Background

Peer support groups reduce psychological morbidity and increase social support for Intensive Care Unit (ICU) survivors. Group formats differ and research, although emerging, is limited. This study explores a continuously running ICU Expert by Experience group, which has a dual role of support and service-user consultative, from attendees' perspectives.

Methods

A thematic analysis was conducted on interviews with current and past members of an ICU Expert by Experience group. 11 participants took part in online and telephone interviews. Three provided written responses. Final themes were created following a process of data validation with participants.

Results

Four main themes emerged: (1) Support in the difficult recovery journey (2) Relationships and shared experiences (3) Value of professional facilitation (4) Practical considerations.

Conclusion

Patients highlighted the help gained from the group as an integral part of their recovery journey. Results also identified practical implications for those considering setting up similar support groups.

The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor’s ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

Longing for homelikeness: A hermeneutic phenomenological analysis of patients' lived experiences in recovery from COVID-19-associated intensive care unit acquired weakness

Aims

To explore lived experiences of patients recovering from COVID‐19‐associated intensive care unit acquired weakness and to provide phenomenological descriptions of their recovery.

Design

A qualitative study following hermeneutic phenomenology.

Methods

Through purposeful sampling, 13 participants with COVID‐19‐associated intensive care unit acquired weakness were recruited with diversity in age, sex, duration of hospitalization and severity of muscle weakness. Semi‐structured in‐depth interviews were conducted from 4 to 8 months after hospital discharge, between July 2020 and January 2021. Interviews were transcribed verbatim and analysed using hermeneutic phenomenological analysis.

Results

The analysis yielded five themes: ‘waking up in alienation’, ‘valuing human contact in isolation’, ‘making progress by being challenged’, ‘coming home but still recovering’ and ‘finding a new balance’. The phenomenological descriptions reflect a recovery process that does not follow a linear build‐up, but comes with moments of success, setbacks, trying new steps and breakthrough moments of achieving mobilizing milestones.

Conclusion

Recovery from COVID‐19‐associated intensive care unit acquired weakness starts from a situation of alienation. Patients long for familiarity, for security and for recognition. Patients want to return to the familiar situation, back to the old, balanced, bodily self. It seems possible for patients to feel homelike again, not only by changing their outer circumstances but also by changing the understanding of themselves and finding a new balance in the altered situation.

Impact

Muscle weakness impacts many different aspects of ICU recovery in critically ill patients with COVID‐19‐associated intensive care unit acquired weakness. Their narratives can help nurses and other healthcare professionals, both inside and outside of the intensive care unit, to empathize with patient experiences. When healthcare professionals connect to the lifeworld of patients, they will start to act and communicate differently. These insights could lead to optimized care delivery and meeting patients' needs in this pandemic or a possible next.

Barriers and facilitators of early mobilisation for intensive care unit delirium: perspectives from patients, family members and carers. A qualitative study protocol

Background/Aims

One-third of patients develop delirium following admission to an intensive care unit. Intensive care unit delirium is associated with poor patient outcomes, including long-term disability and high mortality. Early mobilisation contributes towards the prevention and reduction of intensive care unit delirium. However, the implementation of early mobilisation is infrequent. The aim of this protocol is to explore participants' experiences of the barriers to, and facilitators of, early mobilisation in the adult intensive care unit specific to people experiencing delirium.

Methods

Three moderators will carry out up to six focus groups including up to five participants in each group. Focus group discussions will be used to explore the experiences of patients, carers and family members using Microsoft Teams. Participants will be recruited from the charity ICUsteps using a purposive sampling technique.

Results

Discussions will be audio-recorded and simultaneously transcribed verbatim using the otter.ai programme. Member check approval will be sought to ensure accuracy of data. Framework analysis using a thematic methodology will identify themes in the data.

Conclusions

It is anticipated that the findings of this study will contribute towards further understanding the implementation of early mobilisation in order to improve measures for prevention and management of delirium in the adult intensive care unit.

Psychological Recovery after Critical Illness and Stay in Hospital ICU

Abstract The effects of critical illness and hospitalization in intensive care units (ICU) have been associated with the presence of negative psychological consequences. This study explores the experiences of sick people who were admitted to an ICU, seeking to know its repercussions on the self. In-depth qualitative interviews and participant observations were carried out with two people since their ICU admission until at least six months after discharge from the unit. Data was analyzed following an adaptation of the clinical qualitative method within a longitudinal frame and interpreted with Winnicott’s psychoanalytic perspective. This research managed to describe participants’ lived experiences and the ways they affected their psychic organization. To the interviewed, these experiences configured threshold situations which promoted a process of psychic disintegration. Psychological recovery, then, depends on the articulation of lived experiences, and is supported by facilitating intersubjective relationships that promote the expression of personal potentialities.

Processing Intensive Care Unit Treatment Experiences: A Thematic Analysis of a Diary Intervention

Survivors of the intensive care unit (ICU) report an aggregate of burdensome memories. ICU diaries have been proposed to address the psychological impact of ICU treatment. Twenty-six participants wrote about their ICU experiences in three successive sessions, while in the second session, they were presented with a dairy derived from their medical records. Using inductive thematic analysis in the first and third narratives, we explore how participants initially describe their ICU experience and how they process it after the intervention. Participants described a martyrdom experience, including being emotionally distressed, disorientated, and physically trapped that provoked a quest for any available interpersonal support. A vacuum-like state permeated their existence, impacted their sense-making ability, and the proximity to death uniquely characterized this experience. After intervention, participants made small but significant changes in their written narratives. They appeared to reorganize their recollections, reestablish self-continuity by integrating their ICU experiences, and authored restitution narratives.

SPLIT ENZ: Survivorship of Patients post Long Intensive care stay, Exploration/Experience in a New Zealand cohort (A mixed methods study protocol) (Preprint)

Background

Post Intensive Care Syndrome (PICS) was defined by the Society of Critical Care Medicine in 2012 with subsequent international research highlighting poor long-term outcomes; reduced quality of life; and impairments, for survivors of critical illness. To date, there has been no published research on the long-term outcomes of survivors of critical illness in New Zealand.

Objective

The aim of this study is to explore long-term outcomes after critical illness in New Zealand. The primary objectives are to describe and quantify symptoms and disability, explore possible risk factors, and to identify unmet needs in survivors of critical illness.

Methods

This will be a mixed methods study with 2 components. First, a prospective cohort study of approximately 100 participants with critical illness will be followed up at 1, 6, and 12 months after hospital discharge. The primary outcome will be disability assessed using the World Health Organization Disability Assessment Scale 2.0. Secondary outcomes will focus on mental health using the Hospital Anxiety and Depression Scale and the Impact of Events Scale-revised, cognitive function using the Montreal Cognitive Assessment (Montreal Cognitive Assessment–BLIND), and health-related quality of life using the European Quality of Life-Five Dimension-Five Level. The second element of the study will use qualitative grounded theory methods to explore participants experiences of recovery and highlight unmet needs.

Results

This study was approved by the New Zealand Northern A Health and Disability Ethics Committee on August 16, 2021 (21/NTA/107), and has been registered with the Australian New Zealand Clinical Trials Registry on October 5, 2021. SPLIT ENZ is due to start recruitment in early 2022, aiming to enroll 125 patients over 2 years. Data collection is estimated to be completed by 2024-2025 and will be published once all data are available for reporting.

Conclusions

Although international research has identified the prevalence of PICS and the extent of disability in survivors of critical illness, there is no published research in New Zealand. Research in this field is particularly pressing in the context of COVID-19, an illness that may include PICS in its sequelae.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN1262100133588; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382566&showOriginal=true&isReview=true

International Registered Report Identifier (IRRID)

PRR1-10.2196/35936

Theorising survivorship after intensive care: A systematic review of patient and family experiences

AIMS AND OBJECTIVE

This systematic literature review explores and maps what we know about survivorship to understand how survivorship can be theoretically defined.

BACKGROUND

Survivorship of critical illness has been identified as a challenge for the 21st Century. Whilst the use of the term 'survivorship' is now common in critical care, it has been borrowed from the cancer literature where the discourse on what survivorship means in a cancer context is ongoing and remains largely descriptive. In the absence of a theoretical understanding, the term 'survivorship' is often used in critical illness in a generic way, limiting our understanding of what survivorship is. The current COVID-19 pandemic adds to an urgency of understanding what intensive care unit (ICU) survivorship might mean, given the emerging long-term consequences of this patient cohort. We set out to explore how survivorship after critical illness is being conceptualised and what the implications might be for clinical practice and research.

DESIGN

Integrated systematic literature review. The review protocol was registered with PROSPERO International Prospective Register of Systematic Reviews. PRISMA guidelines were followed and a PRISMA checklist for reporting systematic reviews completed.

RESULTS

The three main themes around which the reviewed studies were organised are: (a) healthcare system; (b) ICU survivors' families; and (c) ICU survivor's identity. These three themes feed into an overarching core theme of 'ICU Survivorship Experiences'. These themes map our current knowledge of what happens when a patient survives a critical illness and where we are in understanding ICU survivorship.

CONCLUSION

We mapped in this systematic review the different pieces of the jigsaw that emerge following critical illness to understand and see the bigger picture of what happens after patients survive critical illness. It is evident that existing research has mapped these connections, but what we have not managed to do yet is defining what survivorship is theoretically. We offer a preliminary definition of survivorship as a process but are aware that this definition needs to be developed further with patients and families.

Challenges of the patient transition process from the intensive care unit: a qualitative study

Background

The transition of patients from the intensive care unit (ICU) to the general ward is challenging. This study aimed to explain the challenges that patients face during the transition process.

Methods

In this qualitative research of conventional content analysis, data collection was conducted between February 2018 and July 2019 in educational hospitals. After obtaining informed consent, purposive sampling was performed with 22 nurses, intensive care physicians, anesthesiologists, and patients and their families using in-depth semi-structured interviews until data saturation.

Results

The content analysis yielded three main themes in the challenges patients face during the transition process from the ICU: mixed feelings regarding transition (happiness/hope, worry/uncertainty, abandonment); care break (different atmosphere, the difference between the program and the quality of care, assigning care to the patient and family, and care culture and beliefs); and search for support and information (ineffective communication, self-care capacity of patient and family, ineffective and disrupted training, and weak follow-up programs), which inflicts care shock in the patients.

Conclusions

The results showed that patients and their families were in a state of care shock during the ICU transition process and were sometimes disconcerted. It is necessary to design and implement care models according to the needs and challenges patients face during the transition period from ICU (patient-centered), based on the evidence available, and after considering the field of medicine and the accessibility of care in the country. The transition process can be improved and enhanced by obtaining knowledge about ICU care and related challenges as well as organizing a learning environment.

Post-Intensive Care Unit Care. A Qualitative Analysis of Patient Priorities and Implications for Redesign

Rationale: Although survival during critical illness is improving, little evidence exists to guide post-intensive care unit (ICU) care. Understanding patients' needs and priorities is fundamental to improving care quality.Objectives: To describe the evolution of patients' priorities for recovery across the spectrum of post-ICU care.Methods: This was a secondary analysis of 39 semistructured interviews conducted from 2005 to 2006 in participants' homes 19 days to 11 years after hospital discharge after critical illness. Adult critical illness survivors (N = 39) aged 20 years or older from multiple ICUs across the United Kingdom were purposively selected to maximize diversity with respect to time since diagnosis, disease severity, sex, age, ethnicity, socioeconomic group/status, region. age, ICU admitting diagnoses, and length of stay. We used the method of qualitative description to characterize patients' priorities for recovery and their evolution within and between individual patients across three post-ICU periods: ICU transition to wards, early period (approximately the first 2 mo) after discharge to home, and late period (>2 mo) after discharge to home.Results: The analysis revealed 12 core patient priorities during recovery: feeling safe, being comfortable, engaging in mobility, participating in self-care, asserting personhood, connecting with people, ensuring family well-being, going home, restoring psychological health, restoring physical health, resuming previous roles and routines, and seeking new life experiences. In general, priorities evolved from those pertaining to basic survival during the stay on wards to being broader and more aspirational by the late postdischarge period.Conclusions: Understanding patients' priorities for post-ICU care is critical for developing stakeholder-driven clinical guidelines. Engaging other stakeholders (e.g., family members, healthcare providers, and institutionalized and frail older adults) to inform the development of clinical guidelines for post-ICU care, together with the barriers and facilitators faced in achieving patient- and family-centered care, is an important next step.

ECMO survivors' quality of life and needs after discharge: A descriptive, comparative cross-sectional pilot study

OBJECTIVES

To describe gender differences in health-related quality of life and characterise discharged patients' perceptions of follow-up needs after extracorporeal membrane oxygenation.

RESEARCH METHODOLOGY/DESIGN

A descriptive, comparative cross-sectional pilot design was used. Adult patients receiving extracorporeal membrane oxygenation discharged between January 1, 2016 and March 31, 2018 participated in telephone interviews.

SETTING

A 580-bed community teaching hospital in south central Pennsylvania.

MAIN OUTCOME MEASURES

Health-related quality of life was measured with the Rand 36-item Short Form Health Survey. Open-ended questions identified post-discharge healthcare services and perceived follow-up needs.

RESULTS

Of 30 eligible patients, 24 completed a telephone interview. All health-related quality of life dimensions, except for role-emotional and mental health, were lower in post- extracorporeal membrane oxygenation patients at follow-up compared to national norms. Women scored lower than men in all health-related quality of life dimensions. The most frequent post-discharge services used were physical therapy (66.7%), rehabilitation (62.5%) and occupational therapy (54.2%). The need for coordination of care post-discharge was identified.

CONCLUSIONS

Given long-term sequelae of extracorporeal membrane oxygenation on health-related quality of life and gender differences in health-related quality of life outcomes, ongoing interdisciplinary follow-up is imperative to ensure comprehensive patient management across the continuum of care.

Nutrition intake in the post-ICU hospitalization period

PURPOSE OF REVIEW

The care of critically ill patients has evolved over recent years, resulting in significant reductions in mortality in developed countries; sometimes with prolonged issues with recovery. Nutrition research has focused on the early, acute period of critical illness, until more recently, where the post-ICU hospitalization period in critical care survivors has become a focus for nutrition rehabilitation. In this period, nutrition rehabilitation may be a vital component of recovery.

RECENT FINDINGS

Overall, oral nutrition is the most common mode of nutrition provision in the post-ICU period. Compared with oral intake alone, calorie and protein requirements can be better met with the addition of oral supplements and/or enteral nutrition to oral intake. However, calorie and protein intake remains below predicted targets in the post-ICU hospitalization period. Achieving nutrition targets are complex and multifactorial, but can primarily be grouped into three main areas: patient factors; clinician factors; and system factors.

SUMMARY

A nutrition intervention in the post-ICU hospitalization period may provide an opportunity to improve survival and functional recovery. However, there are multiple barriers to the delivery of calculated nutrition requirements in this period, a limited understanding of how this can be improved and how this translates into clinical benefit.

A pilot survey of ventilated cancer patients' perspectives and recollections of early mobility in the intensive care unit

Purpose

To determine the level of recall, satisfaction, and perceived benefits of early mobility (EM) among ventilated cancer patients after extubation in the intensive care unit (ICU).

Methods

A survey of patients’ perceptions and recollections of EM was administered within 72 h of extubation. Data on recall of EM participation, activities achieved, adequacy of staffing and rest periods, strength to participate, activity level of difficulty, satisfaction with staff instructions, breathing management, and overall rating of the experience were analyzed. The Confusion Assessment Method for ICU (CAM-ICU) was used for delirium screening.

Results

Fifty-four patients comprised the study group. Nearly 90% reported satisfaction with instructions, staffing, rest periods, and breathing management during EM. Participants indicated that EM maintained their strength (67%) and gave them control over their recovery (61%); a minority felt optimistic (37%) and safe (22%). Patients who achieved more sessions and “out-of-bed” exercises had better recall of actual activities compared with those who exercised in bed. Overall, patients with CAM-ICU-positive results (33%) performed less physical and occupational therapy exercises.

Conclusions

Ventilated cancer patients reported an overall positive EM experience, but factual memory impairment of EM activities was common. These findings highlight the needs and the importance of shaping strategies to deliver a more patient focused EM experience.

Electronic supplementary material

The online version of this article (10.1007/s00520-019-04867-1) contains supplementary material, which is available to authorized users.

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.

Implementation and evaluation of a follow-up programme after intensive care treatment: A practice development project

OBJECTIVES

This study aimed to measure the effects of a newly developed follow-up programme on intensive care unit patient quality of care, as perceived by their relatives, and the appropriateness of the programme according to nurses.

METHODS AND SETTING

This before and after implementation study was conducted in a level III intensive care unit for adult patients and related follow-up wards and included 135 intensive care nurses and 105 general ward nurses. The implemented programme included a personalised poster, a revised discharge protocol and follow-up visits on the ward. Eligible relatives of patients who had remained in the intensive care for a minimum of 48 hours were included.

MAIN OUTCOME MEASURES AND RESULTS

Total quality of care and communication were assessed by relatives as high according to the Quality Monitor. Most intensive care nurses evaluated the usefulness of the discharge protocol as positive (71.8% partly/totally agreed) and in accordance with the patients' needs (82.1% partly/totally agreed).

CONCLUSION

Communication and general support as perceived by patients' relatives improved; however, no influence on the total quality of care of the revised discharge protocol was shown. Nurses considered the programme as useful. The intervention might enable nurses to better respond to the instrumental and affective needs of patients and their relatives.

Predicting risk of unplanned hospital readmission in survivors of critical illness: a population-level cohort study

BACKGROUND

Intensive care unit (ICU) survivors experience high levels of morbidity after hospital discharge and are at high risk of unplanned hospital readmission. Identifying those at highest risk before hospital discharge may allow targeting of novel risk reduction strategies. We aimed to identify risk factors for unplanned 90-day readmission, develop a risk prediction model and assess its performance to screen for ICU survivors at highest readmission risk.

METHODS

Population cohort study linking registry data for patients discharged from general ICUs in Scotland (2005-2013). Independent risk factors for 90-day readmission and discriminant ability (c-index) of groups of variables were identified using multivariable logistic regression. Derivation and validation risk prediction models were constructed using a time-based split.

RESULTS

Of 55 975 ICU survivors, 24.1% (95%CI 23.7% to 24.4%) had unplanned 90-day readmission. Pre-existing health factors were fair discriminators of readmission (c-index 0.63, 95% CI 0.63 to 0.64) but better than acute illness factors (0.60) or demographics (0.54). In a subgroup of those with no comorbidity, acute illness factors (0.62) were better discriminators than pre-existing health factors (0.56). Overall model performance and calibration in the validation cohort was fair (0.65, 95% CI 0.64 to 0.66) but did not perform sufficiently well as a screening tool, demonstrating high false-positive/false-negative rates at clinically relevant thresholds.

CONCLUSIONS

Unplanned 90-day hospital readmission is common. Pre-existing illness indices are better predictors of readmission than acute illness factors. Identifying additional patient-centred drivers of readmission may improve risk prediction models. Improved understanding of risk factors that are amenable to intervention could improve the clinical and cost-effectiveness of post-ICU care and rehabilitation.

Developing and evaluating an instrument to measure Recovery After INtensive care: the RAIN instrument

Background

Measuring and evaluating patients' recovery, following intensive care, is essential for assessing their recovery process. By using a questionnaire, which includes spiritual and existential aspects, possibilities for identifying appropriate nursing care activities may be facilitated. The study describes the development and evaluation of a recovery questionnaire and its validity and reliability.

Methods

A questionnaire consisting of 30 items on a 5-point Likert scale was completed by 169 patients (103 men, 66 women), 18 years or older (m=69, SD 12.5) at 2, 6, 12 or 24 months following discharge from an ICU. An exploratory factor analysis, including a principal component analysis with orthogonal varimax rotation, was conducted. Ten initial items, with loadings below 0.40, were removed. The internal item/scale structure obtained in the principal component analysis was tested in relation to convergent and discrimination validity with a multi-trait analysis. Items consistency and reliability were assessed by Cronbach's alpha and internal item consistency. Test of scale quality, the proportion of missing values and respondents' scoring at maximum and minimum levels were also conducted.

Results

A total of 20 items in six factors - forward looking, supporting relations, existential ruminations, revaluation of life, physical and mental strength and need of social support were extracted with eigen values above one. Together, they explained 75% of the variance. The half-scale criterion showed that the proportion of incomplete scale scores ranged from 0% to 4.3%. When testing the scale's ability to differentiate between levels of the assessed concept, we found that the observed range of scale scores covered the theoretical range. Substantial proportions of respondents, who scored at the ceiling for forward looking and supporting relations and at floor for the need of social support, were found. These findings should be further investigated.

Conclusion

The factor analysis, including discriminant validity and the mean value for the item correlations, was found to be excellent. The RAIN instrument could be used to assess recovery following intensive care. It could provide post-ICU clinics and community/primary healthcare nurses with valuable information on which areas patients may need more support.

Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE). Early evaluation of a complex intervention

BACKGROUND

Many patients suffer significant physical, social and psychological problems in the months and years following critical care discharge. At present, there is minimal evidence of any effective interventions to support this patient group following hospital discharge. The aim of this project was to understand the impact of a complex intervention for ICU survivors.

METHODS

Quality improvement project conducted between September 2014 and June 2016, enrolling 49 selected patients from one ICU in Scotland. To evaluate the impact of this programme outcomes were compared to an existing cohort of patients from the same ICU from 2008-2009. Patients attended a five week peer supported rehabilitation programme. This multidisciplinary programme included pharmacy, physiotherapy, nursing, medical, and psychology input. The primary outcome in this evaluation was the EQ-5D, a validated measure of health-related quality of life. The minimally clinically important difference (MCID) in the EQ-5D is 0.08. We also measured change in self-efficacy over the programme duration. Based on previous research, this study utilised a 2.4 (6%) point change in self-efficacy scores as a MCID.

RESULTS

40 patients (82%) completed follow-up surveys at 12 months. After regression adjustment for those factors known to impact recovery from critical care, there was a 0.07-0.16 point improvement in quality of life for those patients who took part in the intervention compared to historical controls from the same institution, depending on specific regression strategy used. Self-efficacy scores increased by 2.5 points (6.25%) over the duration of the five week programme (p = 0.003), and was sustained at one year post intervention. In the year following ICU, 15 InS:PIRE patients returned to employment or volunteering roles (88%) compared with 11 (46%) in the historical control group (p = 0.15).

CONCLUSIONS AND RELEVANCE

This historical control study suggests that a complex intervention may improve quality of life and self-efficacy in survivors of ICU. A larger, multi-centre study is needed to investigate this intervention further.

Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies

PURPOSE

To identify, evaluate and synthesise studies examining the barriers and enablers for survivors of critical illness to participate in physical activity in the ICU and post-ICU settings from the perspective of patients, caregivers and healthcare providers.

METHODS

Systematic review of articles using five electronic databases: MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus. Quantitative and qualitative studies that were published in English in a peer-reviewed journal and assessed barriers or enablers for survivors of critical illness to perform physical activity were included. Prospero ID: CRD42016035454.

RESULTS

Eighty-nine papers were included. Five major themes and 28 sub-themes were identified, encompassing: (1) patient physical and psychological capability to perform physical activity, including delirium, sedation, illness severity, comorbidities, weakness, anxiety, confidence and motivation; (2) safety influences, including physiological stability and concern for lines, e.g. risk of dislodgement; (3) culture and team influences, including leadership, interprofessional communication, administrative buy-in, clinician expertise and knowledge; (4) motivation and beliefs regarding the benefits/risks; and (5) environmental influences, including funding, access to rehabilitation programs, staffing and equipment.

CONCLUSIONS

The main barriers identified were patient physical and psychological capability to perform physical activity, safety concerns, lack of leadership and ICU culture of mobility, lack of interprofessional communication, expertise and knowledge, and lack of staffing/equipment and funding to provide rehabilitation programs. Barriers and enablers are multidimensional and span diverse factors. The majority of these barriers are modifiable and can be targeted in future clinical practice.

Patient outcomes after critical illness: a systematic review of qualitative studies following hospital discharge

BACKGROUND

There is growing interest in patient outcomes following critical illness, with an increasing number and different types of studies conducted, and a need for synthesis of existing findings to help inform the field. For this purpose we conducted a systematic review of qualitative studies evaluating patient outcomes after hospital discharge for survivors of critical illness.

METHODS

We searched the PubMed, EMBASE, CINAHL, PsycINFO, and CENTRAL databases from inception to June 2015. Studies were eligible for inclusion if the study population was >50 % adults discharged from the ICU, with qualitative evaluation of patient outcomes. Studies were excluded if they focused on specific ICU patient populations or specialty ICUs. Citations were screened in duplicate, and two reviewers extracted data sequentially for each eligible article. Themes related to patient outcome domains were coded and categorized based on the main domains of the Patient Reported Outcomes Measurement Information System (PROMIS) framework.

RESULTS

A total of 2735 citations were screened, and 22 full-text articles were eligible, with year of publication ranging from 1995 to 2015. All of the qualitative themes were extracted from eligible studies and then categorized using PROMIS descriptors: satisfaction with life (16 studies), including positive outlook, acceptance, gratitude, independence, boredom, loneliness, and wishing they had not lived; mental health (15 articles), including symptoms of post-traumatic stress disorder, anxiety, depression, and irritability/anger; physical health (14 articles), including mobility, activities of daily living, fatigue, appetite, sensory changes, muscle weakness, and sleep disturbances; social health (seven articles), including changes in friends/family relationships; and ability to participate in social roles and activities (six articles), including hobbies and disability.

CONCLUSION

ICU survivors may experience positive emotions and life satisfaction; however, a wide range of mental, physical, social, and functional sequelae occur after hospital discharge. These findings are important for understanding patient-centered outcomes in critical care and providing focus for future interventional studies aimed at improving outcomes of importance to ICU survivors.

PReventing early unplanned hOspital readmission aFter critical ILlnEss (PROFILE): protocol and analysis framework for a mixed methods study

INTRODUCTION

Survivors of critical illness experience multidimensional disabilities that reduce quality of life, and 25-30% require unplanned hospital readmission within 3 months following index hospitalisation. We aim to understand factors associated with unplanned readmission; develop a risk model to identify intensive care unit (ICU) survivors at highest readmission risk; understand the modifiable and non-modifiable readmission drivers; and develop a risk assessment tool for identifying patients and areas for early intervention.

METHODS AND ANALYSIS

We will use mixed methods with concurrent data collection. Quantitative data will comprise linked healthcare records for adult Scottish residents requiring ICU admission (1 January 2000-31 December 2013) who survived to hospital discharge. The outcome will be unplanned emergency readmission within 90 days of index hospital discharge. Exposures will include pre-ICU demographic data, comorbidities and health status, and critical illness variables representing illness severity. Regression analyses will be used to identify factors associated with increased readmission risk, and to develop and validate a risk prediction model. Qualitative data will comprise recorded/transcribed interviews with up to 60 patients and carers recently experiencing unplanned readmissions in three health board regions. A deductive and inductive thematic analysis will be used to identify factors contributing to readmissions and how they may interact. Through iterative triangulation of quantitative and qualitative data, we will develop a construct/taxonomy that captures reasons and drivers for unplanned readmission. We will validate and further refine this in focus groups with patients/carers who experienced readmissions in six Scottish health board regions, and in consultation with an independent expert group. A tool will be developed to screen for ICU survivors at risk of readmission and inform anticipatory interventions.

ETHICS AND DISSEMINATION

Data linkage has approval but does not require ethical approval. The qualitative study has ethical approval. Dissemination with key healthcare stakeholders and policymakers is planned.

TRIAL REGISTRATION NUMBER

UKCRN18023.

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).

Follow-up visit in an ICU: receiving a sense of coherence

AIM

To describe patients' experiences of a follow-up visit to an intensive care unit (ICU) after being critically ill and nursed there.

BACKGROUND

Knowledge about the follow-up visit needs to be developed, with the previously critically ill patient in focus.

DESIGN

Qualitative descriptive.

METHOD

Semi-structured interviews were conducted with nine patients and analysed using qualitative content analysis. The data collection occurred during spring 2014.

FINDINGS

During the follow-up visits in ICU, the relatives, the patient diary, and those who took part in the care contribute to fill memory gaps to create a picture and an explanation of the care period.

CONCLUSION

The follow-up visit is an important tool in the patients' struggle to create a context and coherence from a missing or unreal time. The patient diary is essential to subsequently be able to relate to the period of care.

RELEVANCE TO CLINICAL PRACTICE

The follow-up visit, together with a personal diary, after an ICU stay could be seen as significant for strengthening the patients' feeling of coherence and better health.

The use, prevalence and potential benefits of a diary as a therapeutic intervention/tool to aid recovery following critical illness in intensive care: a literature review

AIMS AND OBJECTIVES

To critically appraise the available literature and summarise the evidence related to the use, prevalence, purpose and potential therapeutic benefits of intensive care unit diaries following survivors' discharge from hospital and identify areas for future exploration.

BACKGROUND

Intensive care unit survivorship is increasing as are associated physical and psychological complications. These complications can impact on the quality of life of survivors and their families. Rehabilitation services for survivors have been sporadically implemented and lack an evidence base. Patient diaries in intensive care have been implemented in Scandinavia and Europe with the intention of filling memory gaps, enable survivors to set realistic recovery goals and cement their experiences in reality.

DESIGN

A review of original research articles.

METHODS

The review used key terms and Boolean operators across a 34-year time frame in: CIHAHL, Medline, Scopus, Proquest, Informit and Google Scholar for research reports pertaining to the area of enquiry. Twenty-two original research articles met the inclusion criteria for this review.

RESULTS

The review concluded that diaries are prevalent in Scandinavia and parts of Europe but not elsewhere. The implementation and ongoing use of diaries is disparate and international guidelines to clarify this have been proposed. Evidence which demonstrates the potential of diaries in the reduction of the psychological complications following intensive care has recently emerged. Results from this review will inform future research in this area.

CONCLUSIONS

Further investigation is warranted to explore the potential benefits of diaries for survivors and improve the evidence base which is currently insufficient to inform practice. The exploration of prospective diarising in the recovery period for survivors is also justified.

RELEVANCE TO CLINICAL PRACTICE

Intensive care diaries are a cost effective intervention which may yield significant benefits to survivors.

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.

Life after critical illness: an overview

AIMS AND OBJECTIVES

To illustrate the potential physical and psychological problems faced by patients after an episode of critical illness, highlight some of the interventions that have been tested and identify areas for future research.

BACKGROUND

Recovery from critical illness is an international problem and as an issue is likely to increase. For some, recovery from critical illness is prolonged, subject to physical and psychological problems that may negatively impact upon health-related quality of life.

METHODS

The literature accessed for this review includes the work of a number of key researchers in the field of critical care research. These were identified from a number of sources include (1) personal knowledge of the research field accumulated over the last decade and (2) using the search engine 'The Knowledge Network Scotland'.

RESULTS

Fatigue and weakness are significant problems for critical care survivors and are common in patients who have been in ICU for more than one week. Psychological problems include anxiety, depression, post-traumatic stress, delirium and cognitive impairment. Prevalence of these problems is difficult to establish for a number of methodological reasons that include the use of self-report questionnaires, the number of different questionnaires used and the variation in administration and timing. Certain subgroups of ICU survivors especially those at the more severe end of the illness severity spectrum are more at risk and this has been demonstrated for both physical and psychological problems. Findings from international studies of a range of potential interventions are presented. However, establishing effectiveness for most of these still has to be empirically demonstrated.

CONCLUSION

What seems clear is the need for a co-ordinated, multidisciplinary, designated recovery and rehabilitation pathway that begins as soon as the patient is admitted into an intensive care unit.

Strategies for post ICU rehabilitation

PURPOSE OF REVIEW

As numbers of patients who survive a critical illness increase, often within a context of comorbidities and acquired physical, mental or cognitive sequelae [postintensive care syndrome (PICS)], identifying effective recovery and rehabilitation strategies is paramount. In this review, we discuss recent studies that inform our developing understanding for improving the recovery trajectory for survivors of a critical illness during the postintensive care and posthospital periods.

RECENT FINDINGS

New studies, although at this stage often presented as pilot work, provide important beginning messages for improving recovery from a critical illness. Some pilot studies demonstrate promise of effective interventions, whereas other studies offer useful baseline information for improving the power of tested interventions.

SUMMARY

Innovative rehabilitation and recovery strategies during the postintensive care and posthospital periods are now being published. Further research with larger sample sizes, well-documented usual care and intervention arms and in different critical illness cohorts is required to demonstrate the optimal approaches for screening, implementation, outcome assessment and follow-up periods for rehabilitation interventions in the postintensive care phase of a patient's recovery.