Towards a new orientation: a qualitative longitudinal study of an intensive care recovery programme

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.

Impact of the person-centred intervention guided self-determination across healthcare settings-An integrated review

AIM

To review the evidence of the existing literature on the impact of guided self-determination across methodologies in different healthcare settings.

METHODS

An integrated five-stage review.

RESULTS

Forty-five eligible papers were included. Guided self-determination was applied in full- or small-scale, or combined with another intervention or approach in different healthcare settings handling, for example diabetes, stroke survivorship, schizophrenia, attention-deficit hyperactivity disorder and medical disorder, gynaecological and breast cancer, endometriosis, persons with chronic pain, persons in haemodialysis and intensive care survivors. The included studies covered 12 randomised trials, 26 qualitative and seven papers of different methodology. A statistically significant effect was found in three trials. Six main themes describe the qualitative findings across papers on patients: (1) Guided self-determination reduces disease-related loneliness, (2) Insight enables integration of life and disease, (3) Reflection sheets-appreciated but challenging tool to prompt insights and person-specific knowledge, (4) New person-specific knowledge enables person-centred support, (5) Feeling seen and believed in a new and trusted relationship and (6) Exchange of knowledge enables the development of life skills. Four themes describe the healthcare professionals' experience: (1) Change of usual practice-a decision from above, (2) A new role-unlearning previous behaviour and need for support, (3) Reflection sheets as facilitators and barriers and (4) Discovering the benefits of changing to a person-centred approach.

CONCLUSION

Overall, guided self-determination proved to have a great impact on patient important outcomes and was useful and well-accepted by the majority of patients and healthcare professionals. Albeit guided self-determination is not a 'one size fits all' method. Continuous training and supervision of professionals are a necessary mean when implementing guided self-determination to enhance adoption and sustainability in clinical practice.

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 to resuming meaningful daily activities among critical illness survivors in the UK: a qualitative content analysis

OBJECTIVE

To identify critical illness survivors' perceived barriers and facilitators to resuming performance of meaningful activities when transitioning from hospital to home.

DESIGN

Secondary content analysis of semistructured interviews about patients' experiences of intensive care (primary analysis disseminated on the patient-facing website www.healthtalk.org). Two coders characterised patient-perceived barriers and facilitators to resuming meaningful activities. To facilitate clinical application, we mapped the codes onto the Person-Task-Environment model of performance, a patient-centred rehabilitation model that characterises complex interactions among the person, task and environment when performing activities.

SETTING

United Kingdom, 2005-2006.

PARTICIPANTS

39 adult critical illness survivors, sampled for variation among demographics and illness experiences.

RESULTS

Person-related barriers included negative mood or affect, perceived setbacks; weakness or limited endurance; pain or discomfort; inadequate nutrition or hydration; poor concentration/confusion; disordered sleep/hallucinations/nightmares; mistrust of people or information; and altered appearance. Task-related barriers included miscommunication and managing conflicting priorities. Environment-related barriers included non-supportive health services and policies; challenging social attitudes; incompatible patient-family coping (emotional trauma and physical disability); equipment problems; overstimulation; understimulation; and environmental inaccessibility. Person-related facilitators included motivation or attitude; experiencing progress; and religion or spirituality. Task-related facilitators included communication. Environment-related facilitators included support from family, friends or healthcare providers; supportive health services and policies; equipment; community resources; medications; and accessible housing. Barriers decreased and facilitators increased over time. Six barrier-facilitator domains dominated based on frequency and emphasis across all performance goals: mood/motivation, setbacks/progress, fatiguability/strength; mis/communication; lack/community support; lack/health services and policies.

CONCLUSIONS

Critical illness survivors described a comprehensive inventory of 18 barriers and 11 facilitators that align with the Person-Task-Environment model of performance. Six dominant barrier-facilitator domains seem strong targets for impactful interventions. These results verify previous knowledge and offer novel opportunities for optimising patient-centred care and reducing disability after critical illness.

A Novel Approach to ICU Survivor Care: A Population Health Quality Improvement Project

OBJECTIVES

Deliver a novel interdisciplinary care process for ICU survivor care and their primary family caregivers, and assess mortality, readmission rates, and economic impact compared with usual care.

DESIGN

Population health quality improvement comparative study with retrospective data analysis.

SETTING

A single tertiary care rural hospital with medical/surgical, neuroscience, trauma, and cardiac ICUs.

PATIENTS

ICU survivors.

INTERVENTIONS

Reorganization of existing post discharge health care delivery resources to form an ICU survivor clinic care process and compare this new process to post discharge usual care process.

MEASUREMENTS AND MAIN RESULTS

Demographic data, Acute Physiology and Chronic Health Evaluation IV scores, and Charlson Comorbidity Index scores were extracted from the electronic health record. Additional data was extracted from the care manager database. Economic data were extracted from the Geisinger Health Plan database and analyzed by a health economist. During 13-month period analyzed, patients in the ICU survivor care had reduced mortality compared with usual care, as determined by the Kaplan-Meier method (ICU survivor care 0.89 vs usual care 0.71; log-rank p = 0.0108) and risk-adjusted stabilized inverse probability of treatment weighting (hazard ratio, 0.157; 95% CI, 0.058-0.427). Readmission for ICU survivor care versus usual care: at 30 days (10.4% vs 26.3%; stabilized inverse probability of treatment weighting hazard ratio, 0.539; 95% CI, 0.224-1.297) and at 60 days (16.7% vs 34.7%; stabilized inverse probability of treatment weighting hazard ratio, 0.525; 95% CI, 0.240-1.145). Financial data analysis indicates estimated annual cost savings to Geisinger Health Plan ranges from $247,052 to $424,846 during the time period analyzed.

CONCLUSIONS

Our ICU survivor care process results in decreased mortality and a net annual cost savings to the insurer compared with usual care processes. There was no statistically significant difference in readmission rates.

"Finding oneself after critical illness": voices from the remission society

The number of people who survive critical illness is increasing. In parallel, a growing body of literature reveals a broad range of side-effects following intensive care treatment. Today, more attention is needed to improve the quality of survival. Based on nine individual stories of illness experiences given by participants in two focus groups and one individual interview, this paper elaborates how former critically ill patients craft and recraft their personal stories throughout their illness trajectory. The analysis was conducted from a phenomenological perspective and led to the meaning structure; a quest to find oneself after critical illness. In this structure, illness represented a breakdown of the participants' lives, forcing them to develop a new understanding of themselves. Despite acute illness, they felt safe in hospital. Coming home, however, meant a constant balancing between health and illness, and being either in or out of control. To gain a deeper understanding of the participants' narratives of survival, the meaning structure was developed from a phenomenological life world perspective, Heidegger's concept of homelikeness and Arthur Frank's typologies of illness narratives. In conclusion listening to and acknowledging the patients' lived experiences of critical illness may support the patient efforts to establish the newly defined self and hence be vital for recovery. Phenomenology is one approach facilitating care tailored to the patients' lived experience of critical illness and its aftermaths.

Follow-up services for improving long-term outcomes in intensive care unit (ICU) survivors

BACKGROUND

The intensive care unit (ICU) stay has been linked with a number of physical and psychological sequelae, known collectively as post-intensive care syndrome (PICS). Specific ICU follow-up services are relatively recent developments in health systems, and may have the potential to address PICS through targeting unmet health needs arising from the experience of the ICU stay. There is currently no single accepted model of follow-up service and current aftercare programmes encompass a variety of interventions and materials. There is uncertain evidence about whether follow-up services effectively address PICS, and this review assesses this.

OBJECTIVES

Our main objective was to assess the effectiveness of follow-up services for ICU survivors that aim to identify and address unmet health needs related to the ICU period. We aimed to assess effectiveness in relation to health-related quality of life (HRQoL), mortality, depression and anxiety, post-traumatic stress disorder (PTSD), physical function, cognitive function, ability to return to work or education and adverse effects.Our secondary objectives were to examine different models of follow-up services. We aimed to explore: the effectiveness of service organisation (physician- versus nurse-led, face-to-face versus remote, timing of follow-up service); differences related to country (high-income versus low- and middle-income countries); and effect of delirium, which can subsequently affect cognitive function, and the effect of follow-up services may differ for these participants.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2017. We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included randomised and non-randomised studies with adult participants, who had been discharged from hospital following an ICU stay. We included studies that compared an ICU follow-up service using a structured programme and co-ordinated by a healthcare professional versus no follow-up service or standard care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, and synthesised findings. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included five studies (four randomised studies; one non-randomised study), for a total of 1707 participants who were ICU survivors with a range of illness severities and conditions. Follow-up services were led by nurses in four studies or a multidisciplinary team in one study. They included face-to-face consultations at home or in a clinic, or telephone consultations or both. Each study included at least one consultation (weekly, monthly, or six-monthly), and two studies had up to eight consultations. Although the design of follow-up service consultations differed in each study, we noted that each service included assessment of participants' needs with referrals to specialist support if required.It was not feasible to blind healthcare professionals or participants to the intervention and we did not know whether this may have introduced performance bias. We noted baseline differences (two studies), and services included additional resources (two studies), which may have influenced results, and one non-randomised study had high risk of selection bias.We did not combine data from randomised studies with data from one non-randomised study. Follow-up services for improving long-term outcomes in ICU survivors may make little or no difference to HRQoL at 12 months (standardised mean difference (SMD) -0.0, 95% confidence interval (CI) -0.1 to 0.1; 1 study; 286 participants; low-certainty evidence). We found moderate-certainty evidence from five studies that they probably also make little or no difference to all-cause mortality up to 12 months after ICU discharge (RR 0.96, 95% CI 0.76 to 1.22; 4 studies; 1289 participants; and in one non-randomised study 79/259 deaths in the intervention group, and 46/151 in the control group) and low-certainty evidence from four studies that they may make little or no difference to PTSD (SMD -0.05, 95% CI -0.19 to 0.10, 703 participants, 3 studies; and one non-randomised study reported less chance of PTSD when a follow-up service was used).It is uncertain whether using a follow-up service reduces depression and anxiety (3 studies; 843 participants), physical function (4 studies; 1297 participants), cognitive function (4 studies; 1297 participants), or increases the ability to return to work or education (1 study; 386 participants), because the certainty of this evidence is very low. No studies measured adverse effects.We could not assess our secondary objectives because we found insufficient studies to justify subgroup analysis.

AUTHORS' CONCLUSIONS

We found insufficient evidence, from a limited number of studies, to determine whether ICU follow-up services are effective in identifying and addressing the unmet health needs of ICU survivors. We found five ongoing studies which are not included in this review; these ongoing studies may increase our certainty in the effect in future updates. Because of limited data, we were unable to explore whether one design of follow-up service is preferable to another, or whether a service is more effective for some people than others, and we anticipate that future studies may also vary in design. We propose that future studies are designed with robust methods (for example randomised studies are preferable) and consider only one variable (the follow-up service) compared to standard care; this would increase confidence that the effect is due to the follow-up service rather than concomitant therapies.

Family and Support Networks Following Critical Illness

Research highlights the psychosocial impact of critical illness on family who typically adopt a caregiver role to the survivor. We review evidence on informal caregiver psychosocial outcomes and interventional studies designed to improve them. We argue informal caregivers have distinct and complex needs that differ from patients. Interventional studies ought to be designed for this cohort with careful attention paid to the timing of interventions. We consider the influence of social isolation on recovery and discuss service improvement approaches to build social support networks to enhance recovery, where caregivers and survivors are involved in the design of aftercare programs.

Picking up the pieces: Qualitative evaluation of follow-up consultations post intensive care admission

OBJECTIVES

On an intensive care unit at a university hospital in Denmark patients are offered a nurse-led consultation three months post intensive care unit admission, to help them cope with Post Intensive Care Syndrome and identify opportunities for further intervention. The aim of the study was: 1) To describe former intensive care patients' experiences of the consultation, specifically regarding content and setting. 2) To explore the benefits of the consultation in regard to the individual patients' symptoms of Post Intensive Care Syndrome.

METHODS

Focused ethnography was chosen as methodology combining observations and interviews. Ten patients participated in a two-part qualitative study: 1) an observational study of the current follow-up consultation; 2) a semi-structured interview based upon observations and statements arising during the initial consultation. The data was analysed using a hermeneutic-phenomenological approach.

FINDINGS

Content and setting of the consultation were of upmost importance. Revisiting the unit and experiencing the setting in person played a huge role in coping with Post Intensive Care Syndrome. Involving relatives was essential as they were an important part of the patient's rehabilitation.

CONCLUSIONS

Participating in the consultation and revisiting the unit proved important. It helped patients understand their symptoms and make sense of what had happened during their stay in intensive care unit.