Comparative validation of three screening instruments for posttraumatic stress disorder after intensive care

Post-sepsis psychiatric disorder: Pathophysiology, prevention, and treatment

Post-sepsis psychiatric disorder, encompassing anxiety, depression, post-traumatic stress disorder and delirium, is a highly prevalent complication secondary to sepsis, resulting in a marked increase in long-term mortality among affected patients. Regrettably, psychiatric impairment associated with sepsis is frequently disregarded by clinicians. This review aims to summarize recent advancements in the understanding of the pathophysiology, prevention, and treatment of post-sepsis mental disorder, including coronavirus disease 2019-related psychiatric impairment. The pathophysiology of post-sepsis psychiatric disorder is complex and is known to involve blood-brain barrier disruption, overactivation of the hypothalamic-pituitary-adrenal axis, neuroinflammation, oxidative stress, neurotransmitter dysfunction, programmed cell death, and impaired neuroplasticity. No unified diagnostic criteria for this disorder are currently available; however, screening scales are often applied in its assessment. Modifiable risk factors for psychiatric impairment post-sepsis include the number of experienced traumatic memories, the length of ICU stay, level of albumin, the use of vasopressors or inotropes, daily activity function after sepsis, and the cumulative dose of dobutamine. To contribute to the prevention of post-sepsis psychiatric disorder, it may be beneficial to implement targeted interventions for these modifiable risk factors. Specific therapies for this condition remain scarce. Nevertheless, non-pharmacological approaches, such as comprehensive nursing care, may provide a promising avenue for treating psychiatric disorder following sepsis. In addition, although several therapeutic drugs have shown preliminary efficacy in animal models, further confirmation of their potential is required through follow-up clinical studies.

Two-year multidisciplinary follow-up of COVID-19 patients requiring invasive and noninvasive respiratory support

BACKGROUND

COVID-19 patients frequently develop respiratory failure requiring mechanical ventilation. Data on long-term survival of patients who had severe COVID-19 are insufficient. We assessed and compared two-year survival, CT imaging, quality of life, and functional recovery of COVID-19 ARDS patients requiring respiratory support with invasive (IMV) versus noninvasive ventilation (NIV).

METHODS

Patients with COVID-19 pneumonia admitted up to May 28th, 2020, who required IMV or NIV, and survived to hospital discharge were enrolled. Patients were contacted two years after discharge to assess vital status, functional, psychological, and cognitive outcomes using validated scales. Patients with persistent respiratory symptoms or high burden of residual lung damage at previous CT scan received a two-year chest CT scan.

RESULTS

Out of 61 IMV survivors, 98% were alive at two-year follow-up, and 52 completed the questionnaire. Out of 82 survivors receiving NIV only, 94% were alive at two years, and 47 completed the questionnaire. We found no major differences between invasively and noninvasively ventilated patients, with overall acceptable functional recovery. Among the 99 patients completing the questionnaire, 23 have more than moderate exertional dyspnea. Chest CT scans showed that 4 patients (all received IMV) had fibrotic-like changes.

CONCLUSIONS

Patients who received mechanical ventilation due to COVID-19 and were discharged from hospital had a 96% survival rate at the two-year follow-up. There was no difference in overall recovery and quality of life between patients who did and did not require IMV, although respiratory morbidity remains high.

[Psychological Consequences of Intensive Care Treatment of COVID-19 in Patients and Relatives]

OBJECTIVE

In this study, treatment- and disease-associated consequences of intensive care treatment of COVID-19 in patients and relatives were investigated and compared with data from the general population and sepsis patients. In addition, dyadic associations in symptoms of patients and relatives were analyzed.

METHODS

In a monocentric, prospective, non-controlled observational study, patients who underwent intensive care treatment due to Covid-19 disease at Jena University Hospital between November 2020 and March 2021 and their relatives were included. We assessed the long-term outcome between three and six months after discharge from the intensive care unit (ICU) using the Hospital Anxiety and Depression Scale, the Posttraumatic Stress Scale-14, the Multidimensional Fatigue Inventory-10, and the EQ-5D-5L.

RESULTS

Seventy-two patients (Mdn 64 years, 67% men) and 56 relatives (Mdn 60 years, 80% women, 80% partners) were included in the study. 39,4% of the patients reported clinically relevant anxiety symptoms, 38,8% depressive symptoms, and 45,1% PTSD symptoms, with most cases having abnormal scores in multiple symptom domains. Among relatives, a smaller proportion had clinically relevant scores (29,2%/15,3%/31,5%). Compared with the general population, Covid 19 patients reported significantly higher anxiety and fatigue scores and a reduced quality of life. In relatives, significantly higher anxiety scores for women and lower quality of life for men were found. Compared to ICU patients with severe sepsis, Covid-19 patients were found to have significantly higher PTSD symptoms and lower quality of life. Significant dyadic associations were found for anxiety and fatigue.

DISCUSSION

The results of this study on psychological symptoms after ICU treatment confirm findings from previous studies, but also indicate a stronger PTSD symptomatology, which can be explained by the increased traumatizing potential of isolation and protective measures during treatment. Compared to the general population, particularly elevated anxiety scores of the patients are noticeable, which can be explained by the possible risk of re-infection.

CONCLUSION

Psychological long-term consequences of intensive care treatment of Covid-19 disease should be diagnosed and adequately addressed in the outpatient follow-up of affected individuals.

Screening tools for post-intensive care syndrome and post-traumatic symptoms in intensive care unit survivors: A scoping review

BACKGROUND

Evidence suggests that intensive care unit (ICU) survivors often suffer long-term complications such as post-intensive care syndrome (PICS) and post-traumatic stress disorder (PTSD) from critical illness and ICU stay. PICS and PTSD affect both ICU survivors and their families, which overburdens the healthcare systems. Lack of evidence on the comparative psychometric properties of assessment tools is a major barrier in evidence-based screening for post-ICU symptomatology and health-related quality of life.

OBJECTIVES

We aimed to identify existing tools for screening PTSD and PICS in ICU survivors and their families and to examine evidence on the validity, reliability, sensitivity, and specificity of existing tools, as reflected in published peer-reviewed studies.

METHOD

A scoping review based on literature searches (CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Health and Psychosocial Instruments, Dissertations and Theses Global, and Google Scholar) and predefined eligibility criteria was conducted according to current scoping review guidelines.

FINDINGS

We identified 44 studies reporting on the development and assessment of psychometric properties of PICS/PTSD in ICU survivors or families globally. We identified five tools addressing all three aspects of PICS manifestations, one tool for both physical and mental aspects of PICS, and fivefive tools for quality-of-life assessment in ICU survivors. Altogether, 25 tools assess only one aspect of PICS: five for cognitive impairment, seven for physical impairment, and 13 for mental health impairment and PTSD in ICU survivors. However, only two tools were found for PICS-family assessment. Other findings include (i) unclear validity and often limited feasibility of tools, (ii) low diagnostic accuracy of cognitive assessment tools, and (iii) evidence of appropriate psychometric properties and feasibility of psychological health assessment tools.

CONCLUSION

These results have implications for the selection and implementation of the assessment methods as a means for promoting meaningful patient-centred clinical outcomes to minimise long-term sequelae, reduce the rate of rehospitalisation, and optimise recovery after ICU discharge.

The Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5: A Systematic Review of Existing Psychometric Evidence

The PTSD Checklist for DSM-5 (PCL-5) is a widely used self-rated measure of DSM-5 PTSD symptoms. The goal of this systematic review was to synthesize research on the psychometric properties of the PCL-5 to guide clinical and research applications. We focused on reliability, validity, factor structure, optimal cutoff scores, and sensitivity to clinical change indices. A systematic review of the literature following PRISMA guidelines was conducted using PubMed, PsycINFO, CINAHL, and PTSDpubs with search terms capturing selected psychometric indices of the PCL-5. The inclusion criteria were: peer-reviewed publication in English; primary focus on the PCL-5 psychometrics; empirical study; and study with adult samples. The search yielded 265 studies; 56 papers (amounting to 64 studies) met inclusion criteria and were reviewed. Findings generally indicated evidence for: acceptable internal consistency and test-retest reliability; construct validity; a 7-factor Hybrid Model; recommended cutoff scores between 31-33; and ability to index sensitivity to clinical change. To further advance knowledge and applications of the PCL-5, we need more research on abbreviated versions of the PCL-5, bifactor modeling as applied to the PCL-5, as well as on PCL-5 item difficulty estimates, discrimination parameters, and clinical change score estimates.

[Differential Effects of an Internet-Based Cognitive-Behavioral Writing Therapy for Reducing PTSD Symptoms after Intensive Care: Results of a Per-Protocol Analysis]

OBJECTIVE

To investigate the differential effects of an internet-based cognitive-behavioral writing therapy (iCBT) on post-traumatic stress disorder (PTSD) symptoms after intensive care in patients and their spouses.

METHODS

This reanalysis of a randomized controlled trial compared PTSD symptom severity (measured by PCL-5) before and after therapy considering potential influencing factors in the per-protocol population.

RESULTS

A significant reduction in post-traumatic symptom severity after iCBT was found. Eleven of the 25 treated participants showed a clinically significant change (PCL-5 difference≥10 points). The number of words written by the participants in the therapy modules had a significant impact on iCBT efficacy.

CONCLUSION

iCBT appears to be a promising option to augment therapy for PTSD, particularly for physically impaired patients following critical illness.

Scales to measure post intensive care syndrome, a scoping review

INTRODUCTION

Post Intensive Care Syndrome is a recently studied syndrome that affects between 50% and 70% of patients admitted to the ICU, its detection is complex due to the great variety of affected components.

OBJECTIVE

To determine the most widely used assessment instruments for the detection of post-intensive care syndrome, according to the evidence in the last 5 years.

METHODOLOGY

A scoping review was carried out in the databases: Academic Search, ScienceDirect, Scielo, Biblioteca Virtual en Salud, Medline, and Springer Link, with terms «Postintensive care syndrome» and «Post-intensive care syndrome». This review included 22 articles that met the criteria of: research or review typology, English, Spanish or Portuguese language, with access to the full text and published between 2015 and 2020.

CONCLUSIONS

Most of the instruments used to measure post-intensive care syndrome are divided according to the components of physical affectation (the Medical Research Council scale, the Katz index and the Barthel index); cognitive (Repeatable Battery for the Assessment of Neuropsychological Status, and the Montreal Cognitive Assessment test); and mental (Hospital Anxiety and Depression Scale, Beck's anxiety test, Depression Inventory Second Edition scale and Post Traumatic Stress Syndrome-14 scale). In addition, two tools were found that measure the event in its entirety with its three components, such as the Healthy Aging Brain Care Monitor and the Post-Intensive Care Syndrome Questionnaire.

Post-traumatic stress disorder: a psychiatric disorder requiring urgent attention

Post-traumatic stress disorder (PTSD) is a severe and heterogenous psychiatric disorder that was first defined as a mental disorder in 1980. Currently, the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) and the International Classification of Diseases 11th Edition (ICD-11) offer the most widely accepted diagnostic guidelines for PTSD. In both diagnostic categories, experiencing a traumatic event (TE) is the necessary criterion for diagnosing PTSD. The TEs described in the DSM-5 include actual or threatened death, serious injury, sexual violence, and other extreme stressors, either directly or indirectly. More than 70% of adults worldwide are exposed to a TE at least once in their lifetime, and approximately 10% of individuals develop PTSD after experiencing a TE. The important features of PTSD are intrusion or re-experiencing fear memories, pervasive sense of threat, active avoidance, hyperarousal symptoms, and negative alterations of cognition and mood. Individuals with PTSD have high comorbidities with other psychiatric diseases, including major depressive disorder, generalized anxiety disorder, and substance use disorder. Multiple lines of evidence suggest that the pathophysiology of PTSD is complex, involving abnormal neural circuits, molecular mechanisms, and genetic mechanisms. A combination of both psychotherapy and pharmacotherapy is used to treat PTSD, but has limited efficacy in patients with refractory PTSD. Because of the high prevalence, heavy burden, and limited treatments, PTSD is a psychiatric disorder that requires urgent attention. In this review, we summarize and discuss the diagnosis, prevalence, TEs, pathophysiology, and treatments of PTSD and draw attention to its prevention.

One-Year Multidisciplinary Follow-Up of Patients With COVID-19 Requiring Invasive Mechanical Ventilation

OBJECTIVES

Patients with COVID-19 frequently develop acute respiratory distress syndrome (ARDS) requiring intensive care unit (ICU) admission. Data on long-term survival of these patients are lacking. The authors investigated 1-year survival, quality of life, and functional recovery of patients with COVID-19 ARDS requiring invasive mechanical ventilation.

DESIGN

Prospective observational study.

SETTING

Tertiary-care university hospital.

PARTICIPANTS

All patients with COVID-19 ARDS receiving invasive mechanical ventilation and discharged alive from hospital.

INTERVENTIONS

Patients were contacted by phone after 1 year. Functional, cognitive, and psychological outcomes were explored through a questionnaire and assessed using validated scales. Patients were offered the possibility to undergo a follow-up chest computed tomography (CT) scan.

MEASUREMENTS AND MAIN RESULTS

The study included all adult (age ≥18 years) patients with COVID-19-related ARDS admitted to an ICU of the authors' institution between February 25, 2020, and April 27, 2020, who received at least 1 day of invasive mechanical ventilation (IMV). Of 116 patients who received IMV, 61 (52.6%) survived to hospital discharge. These survivors were assessed 1 year after discharge and 56 completed a battery of tests of cognition, activities of daily living, and interaction with family members. They had overall good functional recovery, with >80% reporting good recovery and no difficulties in usual activities. A total of 52 (93%) of patients had no dyspnea at rest. Severe anxiety/depression was reported by 5 (8.9%) patients. Comparing 2-month and 1-year data, the authors observed the most significant improvements in the areas of working status and exertional dyspnea. One-year chest CT scans were available for 36 patients; fibrotic-like changes were present in 4 patients.

CONCLUSIONS

All patients who survived the acute phase of COVID-19 and were discharged from the hospital were alive at the 1-year follow up, and the vast majority of them had good overall recovery and quality of life.

Características del síndrome post cuidado intensivo: revisión de alcance

Objetivo: identificar la evidencia disponible de las características del síndrome post unidad de cuidado intensivo en el paciente que egresa de la unidad de cuidado intensivo. Método: revisión de alcance con la metodología del Joanna Briggs Institut, en cinco bases de datos con la estrategia de búsqueda ([PostIntensive AND Care AND Syndrome] [Nursing AND Care AND PICS]). Se incluyeron estudios primarios publicados entre los años 2010 y 2020, disponibles en texto completo. Resultados: después del análisis de los 48 estudios primarios se extrajeron seis categorías temáticas así: aspecto cognitivo en el síndrome post UCI, osteomusculares, psicoemocionales, estrategias de prevención con modelos de sobrevivientes de UCI, síndrome post unidad cuidado intensivo en la familia y herramientas de evaluación. Conclusiones: mejorar la calidad de atención de los pacientes que presentan este síndrome, prevenir la aparición y aumentar la calidad de vida prestada a los sobrevivientes de UCI y sus familias. La evidencia reporta que entre los cuidadores se pueden desencadenar distintos trastornos que disminuyen su calidad de vida. La enfermería juega un papel crucial en la prevención de la aparición del síndrome mediante estrategias en la UCI e interdisciplinares; los planes de egreso y seguimiento a los pacientes pueden lograr que estos se rehabiliten más rápido y eviten discapacidades o secuelas a largo plazo.

Prevalence and Temporal Trends Analysis of Screening and Diagnostic Instruments in Posttraumatic Stress Disorder: Text Mining Study

BACKGROUND

Various instruments for patient screening and diagnosis have been developed for and applied in posttraumatic stress disorder (PTSD).

OBJECTIVE

This study comprehensively investigates the prevalence and temporal trends of the most widely used instruments in PTSD-related studies.

METHODS

A total of 1345 files of registered clinical trials from ClinicalTrials.gov and 9422 abstracts from the PubMed database from 2005 to 2020 were downloaded for this study. The instruments applied in clinical trials were manually annotated, and instruments in abstracts were recognized using exact string matching. The prevalence score of an instrument in a certain period was calculated as the number of studies divided by the number of instances of the instrument. By calculating the yearly prevalence index of each instrument, we conducted a trends analysis and compared the trends in index change between instruments.

RESULTS

A total of 4178 instrument synonyms were annotated, which were mapped to 1423 unique instruments. In the 16 years from 2005 to 2020, only 10 instruments were used more than once per year; the 4 most used instruments were the PTSD Checklist, the Clinician-Administered PTSD Disorder Scale, the Patient Health Questionnaire, and the Beck Depression Inventory. There were 18 instruments whose yearly prevalence index score exceeded 0.1 at least once during the 16 years. The changes in trends and time points of partial instruments in clinical trials and PubMed abstracts were highly consistent. The average time duration of a PTSD-related trial was 1495.5 days or approximately 4 years from submission to ClinicalTrial.gov to publication in a journal.

CONCLUSIONS

The application of widely accepted and appropriate instruments can help improve the reliability of research results in PTSD-related clinical studies. With extensive text data obtained from real clinical trials and published articles, we investigated and compared the usage of instruments in the PTSD research community.

One-Year Functional, Cognitive, and Psychological Outcomes Following the Use of Extracorporeal Membrane Oxygenation in Coronavirus Disease 2019: A Prospective Study

To prospectively describe 1-year outcomes, with a focus on functional outcome, cognitive outcome, and the burden of anxiety, depression, and post-traumatic stress disorder, in coronavirus disease 2019 patients managed with extracorporeal membrane oxygenation.

Design

Prospective case series.

Setting

Tertiary extracorporeal membrane oxygenation center in the United States.

Patients

Adult coronavirus disease 2019 acute respiratory distress syndrome patients managed with extracorporeal membrane oxygenation March 1, 2020, to July 31, 2020.

Interventions

Baseline variables, treatment measures, and short-term outcomes were obtained from the medical record. Survivors were interviewed by telephone, a year following the index intensive care admission. Functional outcome was assessed using the modified Rankin Scale and the World Health Organization Disability Assessment Scale 2.0. Cognitive status was assessed with the 5-minute Montreal Cognitive Assessment. The Hospital Anxiety and Depression Scale was used to screen for anxiety and depression. Screening for post-traumatic stress disorder was performed with the Posttraumatic Stress Disorder Checklist 5 instrument.

Measurements and Main Results

Twenty-three patients were managed with extracorporeal membrane oxygenation, 14 (61%) survived to hospital discharge. Thirteen (57%) were alive at 1 year. One patient was dependent on mechanical ventilation, another intermittently required supplemental oxygen at 1 year. The median modified Rankin Scale score was 2 (interquartile range, 1-2), median World Health Organization Disability Assessment Scale 2.0 impairment score was 21% (interquartile range, 6-42%). Six of 12 previously employed individuals (50%) had returned to work, and 10 of 12 (83%) were entirely independent in activities of daily living. The median Montreal Cognitive Assessment score was 14 (interquartile range, 13-14). Of 10 patients assessed with Hospital Anxiety and Depression Scale, 4 (40%) screened positive for depression and 6 (60%) for anxiety. Four of 10 (40%) screened positive for post-traumatic stress disorder.

Conclusions

Functional impairment was common a year following the use of extracorporeal membrane oxygenation in coronavirus disease 2019, although the majority achieved independence in daily living and about half returned to work. Long-term anxiety, depression, and post-traumatic stress disorder were common, but cognitive impairment was not.

Management of persistent sinus tachycardia during post-acute rehabilitation in a critical patient with COVID-19: a single-case study

Background

Sinus tachycardia is a common arrhythmia in patients with COVID-19, and may pose challenges during rehabilitation.

Case description

This is a case report of a 39-year-old critically ill patient with COVID-19 with no premorbid conditions, who presented with intensive care unit-acquired weakness and persistent sinus tachycardia after their stay in an intensive care unit. The sinus tachycardia and exertional symptoms contributed to a severely limited exercise capacity (assessed through the 6-Minute Walk Test and 2-Minute Step Test), which impaired the progress of inpatient rehabilitation. This was addressed through the use of bisoprolol for heart rate control and a rehabilitation programme based on cardiac rehabilitation principles.

Results

The patient's intensive care unit-acquired weakness improved with exercise-based rehabilitation, and the Functional Independence Measure motor subscore improved from 54/91 to 91/91 on discharge after 6 weeks of inpatient rehabilitation. After bisoprolol was started for sinus tachycardia, the patient's resting heart rate improved from 106 beats per minute to less than 90 beats per minute during this period of inpatient rehabilitation. During the same period, the patient exhibited concurrent improvement in exercise capacity on weekly 6-Minute Walk Test measurements. Improvements in the 2-Minute Step Test were also documented.

Conclusions

Patient assessment using submaximal exercise testing with serial 6-Minute Walk Tests and 2-Minute Step Tests, along with using beta-blockers and cardiac rehabilitation principles, can be useful in the post-acute rehabilitation of patients recovering from COVID-19 with persistent sinus tachycardia.

Two-months quality of life of COVID-19 invasively ventilated survivors; an Italian single-center study

Background

COVID‐19 disease can lead to severe functional impairments after discharge. We assessed the quality of life of invasively ventilated COVID‐19 ARDS survivors.

Methods

We carried out a prospective follow‐up study of the patients admitted to the Intensive Care Units (ICUs) of a teaching hospital. Patients affected by COVID‐19 ARDS who required invasive ventilation and were successfully discharged home were assessed through the telephone administration of validated tests. We explored survival, functional outcomes, return to work, quality of life, cognitive and psychological sequelae. The main variables of interest were the following: demographics, severity scores, laboratory values, comorbidities, schooling, working status, treatments received during ICU stay, complications, and psychological, cognitive, functional outcomes.

Results

Out of 116 consecutive invasively ventilated patients, overall survival was 65/116 (56%) with no death occurring after hospital discharge. Forty‐two patients were already discharged home with a median follow‐up time of 61 (51‐71) days after ICU discharge and 39 of them accepted to be interviewed. Only one patient (1/39) experienced cognitive decline. The vast majority of patients reported no difficulty in walking (32/35:82%), self‐care (33/39:85%), and usual activities (30/39:78%). All patients were either malnourished (15/39:38%) or at risk for malnutrition (24/39:62%). Exertional dyspnea was present in 20/39 (51%) patients. 19/39 (49%) reported alterations in senses of smell and/or taste either before or after hospitalization.

Conclusions

Invasively ventilated COVID‐19 ARDS survivors have an overall good recovery at a 2‐months follow‐up which is better than what was previously reported in non‐COVID‐19 ARDS patients.

Mid-German Sepsis Cohort (MSC): a prospective observational study of sepsis survivorship

PURPOSE

The Mid-German Sepsis Cohort (MSC) aims to investigate mid-term and long-term functional disabilities in sepsis survivors from intensive care unit (ICU) discharge until 1 year after. Secondary, post-acute mortality and morbidity, health-related quality of life and healthcare utilisation will be investigated.

PARTICIPANTS

The MSC comprises adult (aged ≥18 years) patients who were treated for (severe) sepsis or septic shock on ICU. The participants were recruited between 15 April 2016 and 30 November 2018 from five German centres. Three thousand two hundred and ten patients with sepsis were identified, of which 1968 survived their ICU stay and were eligible for enrolment in the follow-up cohort. Informed consent for follow-up assessment was provided by 907 patients (46.1% of eligible patients).

FINDINGS TO DATE

The recruitment of the participants for follow-up assessments and the baseline data collection is completed. Incidence of sepsis was 116.7 patients per 1000 ICU patients. In this cohort profile, we provide an overview of the demographics and the clinical characteristics of both the overall sepsis cohort and the ICU survivors who provided informed consent for follow-up assessment (907 out of 1968 ICU survivors (46.1%)).

FUTURE PLANS

The follow-ups are conducted 3, 6 and 12 months after ICU discharge. Another yearly follow-up up to 5 years after ICU discharge is pursued. Several cooperation and satellite projects were initiated. This prospective cohort offers a unique resource for research on long-term sequelae of sepsis survivors.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00010050).

Effect of a Videoconference-Based Online Group Intervention for Traumatic Stress in Parents of Children With Life-threatening Illness: A Randomized Clinical Trial

IMPORTANCE

A substantial proportion of parents whose child is diagnosed with a life-threatening illness experience high levels of distress that can lead to long-term mental health difficulties. This can affect the child's recovery.

OBJECTIVE

To evaluate the efficacy of an acceptance and commitment therapy-based group intervention, delivered using videoconferencing, in reducing posttraumatic stress symptoms (PTSS) in these parents.

DESIGN, SETTING, AND PARTICIPANTS

This study was a randomized clinical trial of an intervention for parents with elevated acute stress symptoms. It was a single-site study conducted in a tertiary pediatric hospital in Australia. Parents of children aged 0 to 18 years admitted for a life-threatening illness or injury to the oncology, cardiology, or pediatric intensive care departments were eligible. Participants were screened for eligibility within the first month after diagnosis or admission and then were randomized to the intervention group or the waiting list control group 4 to 10 months after diagnosis or admission. Recruitment commenced January 2014, and final postintervention follow-up was completed in February 2018. Data analysis was performed from July to September 2018.

INTERVENTIONS

Treatment was a psychological acceptance and commitment therapy-based group therapy program called Take a Breath, which consisted of a 6-session parent-mediated psychological intervention delivered via online videoconferences over the course of 8 weeks. Waiting list control participants received treatment as usual and were offered the intervention 3 months after randomization.

MAIN OUTCOMES AND MEASURES

The primary outcome was PTSS, as measured by the Posttraumatic Stress Disorder Checklist-Version 5 (total score range, 0-80, with higher scores indicating greater symptom severity). The PTSS was measured both before and immediately after the intervention. Changes in psychological skills taught within the intervention were also evaluated, including acceptance, mindfulness, values-based living, and psychological flexibility.

RESULTS

Of 1232 parents who were assessed for eligibility, 313 were randomized; 161 were allocated to the waiting list control group, and 152 were allocated to the intervention group. Of those allocated, 44 parents in the waiting list group and 37 in the intervention group completed the postintervention questionnaire and were analyzed (81 participants total; mean [SD] age, 37.17 [6.43] years). Sixty-five participants (80.2%) were women, 48 participants (59.3%) were married, and 40 participants (49.4%) lived in rural or regional areas, or in a different state. In addition, 24 parents (29.6%) were in the cardiology illness group, 32 parents (39.5%) were in the oncology group, and 25 parents (30.9%) were in the pediatric intensive care unit group. The intervention group demonstrated significantly greater improvements in PTSS compared with the waiting list group (Cohen d = 1.10; 95% CI, 0.61-1.59; P = .03). The mean Posttraumatic Stress Disorder Checklist-Version 5 scores decreased from 31.7 (95% CI, 27.0-36.4) to 26.2 (95% CI, 21.8-30.7) in the waiting list control group and from 23.3 (95% CI, 18.6-28.1) to 17.8 (95% CI, 13.8-21.8) in the intervention group.

CONCLUSIONS AND RELEVANCE

The findings of this study support the use of acceptance and commitment therapy to reduce PTSS in parents of very ill children, regardless of diagnosis. These findings also suggest that a brief, group format using a videoconferencing platform can be used effectively to access hard-to-reach populations, particularly fathers and caregivers living in nonmetropolitan areas.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Identifier: ACTRN12611000090910.

A national survey of intensive care follow-up clinics in Australia

BACKGROUND

Intensive care follow-up clinics (ICFCs) have been implemented internationally with the aim to address the growing number of patients living with sequalae of critical illness and intensive care. However, data on Australian intensive care follow-up practice are rare.

OBJECTIVES

The primary objective was to determine the proportion of Australian intensive care units (ICUs) that offer a dedicated ICFC to ICU survivors, with the intention of improving long-term outcomes of critical illness. Secondary objectives were to identify models of ICU follow-up and barriers to the implementation of ICFCs.

METHODS

A custom-designed, pilot-tested 12-question online survey was sent to the nurse unit managers and medical directors of all 167 Australian ICUs listed in the database of the Australian and New Zealand Intensive Care Society. Outcome measures included proportion of ICUs offering ICFCs, details on types of follow-up services with staffing, funding source, and reasons for not providing ICU follow-up.

RESULTS

One hundred seven of the 167 ICUs contacted responded to the survey. Of these, two (2%) operated a dedicated ICFC. Both ICFCs were nursing-led, with one receiving dedicated funding and the other being unfunded. Three units (3%) conducted routine outpatient follow-up by telephone; one of these services was doctor-led, and two were nurse-led. Four units (4%) were performing outpatient follow-up as part of research studies only. Among the units not operating an ICFC, the main reason given for not doing so were financial constraints (58%), followed by lack of clinical need (19%) and perceived lack of evidence (11%).

CONCLUSION

In Australia, only two ICUs operated an ICFC. Only one outpatient follow-up service received dedicated funding, and financial constraints were the main reason given for units not offering outpatient follow-up services.