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

Hong Kong general ward nurses' experiences of transitional care for patients discharged from the intensive care unit: An inductive thematic analysis

OBJECTIVES

The aim of this study was to explore and better understand the experiences of Hong Kong general ward nurses who care for post-intensive care patients.

RESEARCH METHODOLOGY/DESIGN

Inductive thematic analysis and focus groups interviews were used in this study.

SETTING

A purposive sample of 20 ward-based registered nurses were recruited, formed five focus groups and interviewed online using video-conferencing media.

FINDINGS

The ward nurses in this study described the difficulties and challenges they experienced caring for the post-intensive care patient. Issues around workload and patient allocation figured highly along with a lack of education and training. Many felt scared and helpless when caring for these patients which significantly increased their anxiety. Some were compelled to spend more time with their other patients while others were so consumed with the post-ICU patient that they often neglected their other patients. The handover from the intensive care unit nurse was filled with trepidation and concern because of the level of information being handed-over was alien and complex to them so was the medications and the level of monitoring the intensive care unit nurse expected which was not often forthcoming on the ward simply because they didn't know what they were doing.

CONCLUSION

The findings of this study demonstrate that these ward-nurses found themselves in a difficult situation with trying to understand of the needs of the post-intensive care patient. A lack of support, a lack of education and an increased workload made this situation hard. One possible solution is the development and evaluation of a critical care outreach team to support ward-based decision-making. Combined with formal training and education around the acutely ill and /or the deteriorating patient would be a positive step forward.

IMPLICATIONS FOR CLINICAL PRACTICE

The post-intensive care patient poses significant challenges to ward nurses unfamiliar with the level of care they require. Unlike intensive care unit nurses whose focus is on survival and preventing deterioration, the ward nurse's attention is meeting the activities of daily living and progressing the patient's rehabilitation. One of the major obstacle experienced was at handover and the transferring of responsibility where the information conveyed was overly complex and to the ward nurse mostly irrelevant. For this, critical nurses must improve their proficiency at handover so that information is tailored to the needs of the ward environment. One way would be the development of a intensive care unit/Ward handover tool developed collaboratively so as maximise the priorities of care and improve patient outcome.

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

BACKGROUND

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

AIM

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

How to avoid harm with feeding critically ill patients: a synthesis of viewpoints of a basic scientist, dietitian and intensivist

The optimal feeding strategy in critically ill patients is a matter of debate, with current guidelines recommending different strategies regarding energy and protein targets. Several recent trials have added to the debate and question our previous understanding of the provision of nutrition during critical illness. This narrative review aims to provide a summary of interpretation of recent evidence from the view of basic scientist, critical care dietitian and intensivist, resulting in joined suggestions for both clinical practice and future research. In the most recent randomised controlled trial (RCT), patients receiving 6 versus 25 kcal/kg/day by any route achieved readiness for ICU discharge earlier and had fewer GI complications. A second showed that high protein dosage may be harmful in patients with baseline acute kidney injury and more severe illness. Lastly, a prospective observational study using propensity score matched analysis suggested that early full feeding, especially enteral, compared to delayed feeding is associated with a higher 28-day mortality. Viewpoints from all three professionals point to the agreement that early full feeding is likely harmful, whereas important questions regarding the mechanisms of harm as well as on timing and optimal dose of nutrition for individual patients remain unanswered and warrant future studies. For now, we suggest giving low dose of energy and protein during the first few days in the ICU and apply individualised approach based on assumed metabolic state according to the trajectory of illness thereafter. At the same time, we encourage research to develop better tools to monitor metabolism and the nutritional needs for the individual patient accurately and continuously.

Need for social work interventions in the emergency department

This paper reports findings from a qualitative study conducted on the Need for Social work interventions in the Emergency Department (ED) at a large tertiary care center in India. The emergency department is an important social work intervention point for individuals with various psychiatric, medical, and social needs who have little or no additional interaction with social services. Social workers are specially trained to understand the impact of social factors on health outcomes and provide interventions that address social barriers to improving health and accessing community resources; social workers are well prepared to provide services in the emergency department. However, limited research is available to understand the impact of psychosocial services in the emergency department. We aimed to identify areas which require integrated social work services and coordination to address the psychosocial issues within the ED. Interviews with 10 healthcare workers are analyzed thematically. Recurring themes throughout the interviews confirm the need for providing social work interventions to ensure the medical, psychological, and social care needs in the emergency department.

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study

OBJECTIVE

To understand the sociotechnical factors affecting medication safety when intensive care patients are transferred to a hospital ward. Consideration of these medication safety factors would provide a theoretical basis, on which future interventions can be developed and evaluated to improve patient care.

DESIGN

Qualitative study using semistructured interviews of intensive care and hospital ward-based healthcare professionals. Transcripts were anonymised prior to thematic analysis using the London Protocol and Systems Engineering in Patient Safety V.3.0 model frameworks.

SETTING

Four north of England National Health Service hospitals. All hospitals used electronic prescribing in intensive care and hospital ward settings.

PARTICIPANTS

Intensive care and hospital ward healthcare professionals (intensive care medical staff, advanced practitioners, pharmacists and outreach team members; ward-based medical staff and clinical pharmacists).

RESULTS

Twenty-two healthcare professionals were interviewed. We identified 13 factors within five broad themes, describing the interactions that most strongly influenced the performance of the intensive care to hospital ward system interface. The themes were: Complexity of process performance and interactions; Time pressures and considerations; Communication processes and challenges; Technology and systems and Beliefs about consequences for the patient and organisation.

CONCLUSIONS

The complexity of the interactions on the system performance and time dependency was clear. We make several recommendations for policy change and further research based on improving: availability of hospital-wide integrated and functional electronic prescribing systems, patient flow systems, sufficient multiprofessional critical care staffing, knowledge and skills of staff, team performance, communication and collaboration and patient and family engagement.

Lessons from a review of physiotherapy and psychological rehabilitation received during ICU stay and beyond to inform the development of an ICU follow clinic

BACKGROUND

Critical illness can have a long-term impact. A service evaluation was conducted in a hospital in the south west of Britain with an adult inter-connected general, surgical and neurological intensive care unit (ICU). The aim of the service evaluation was to generate knowledge on experiences of psychological and physical rehabilitation in intensive care, on other hospital wards and at home to inform the development of an Intensive Care follow up clinic.

METHOD

Data was collected from two sources. A week of ICU discharges was randomly selected, and a sample of 30 patients generated. All were sent information sheets and consent forms and offered telephone appointments. 12 participants took part in telephone interviews. The second source of participants was the ICU Expert by Experience group. Informed consent was gained with eight participants taking part. The data was analysed using thematic analysis, employing initial open coding to build a framework of emergent themes. A research group was formed to facilitate cross coding of extracts.

RESULTS

The analysis identified three overarching themes: sense making difficulties; rehabilitation context; and sense of self. The theme of sense making difficulties had sub-themes of memory gaps, delirium, lack of information and anxiety. The theme of rehabilitation context had sub-themes of ICU environment, transitions, isolation and abandonment and valued support.

CONCLUSION

the process of sense making can be difficult, is filtered through contextual factors, and may influence sense of self. The results have been used to inform the development of an ICU follow up clinic.

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.

Multidisciplinary team perception of games-based therapy in critical care: A service evaluation

BACKGROUND

As survivorship following critical illness improves, there is greater focus on maximizing recovery. As well as physical effects, critical illness often results in cognitive impairments such as delirium, anxiety, or disorientation. In other populations, such as delirium, non-pharmacological approaches to manage these conditions are preferred, including re-orientation and ensuring personal care needs are met. Cognitive rehabilitation is also well documented for patients with neuropsychological deficits. Treatments include memory aids, compensation strategies, and functional execution. In other hospital populations, games and activities have been utilized to optimize patient engagement, stimulation, and aid recovery, but it is considered an emerging therapy in intensive care.

AIMS

This service evaluation aimed to gather multidisciplinary team members' perceptions of the use of games based therapy (GBT) in critical care, including patient engagement and acceptability in clinical practice.

STUDY DESIGN

A UK-based single-centre qualitative service evaluation.

METHODS

Purposive sampling was used to identify interviewees within an adult intensive care who had experience of using a recently implemented GBT intervention. Qualitative data were collected through semi-structured interviews, which were recorded and transcribed verbatim. Data were analysed using thematic analysis.

RESULTS

Eight staff members across the multidisciplinary team were interviewed. One overarching theme of humanizing health care was identified, with three sub-themes of enhancing recovery, non-physical components of care, and bespoke tailoring. In addition, further recommendations for development of the service were summarized.

CONCLUSION

GBT was well received by staff in clinical practice. It was described as a supportive adjunct to traditional care and rehabilitation, enhancing staff-patient relationships. While it was recognized it may not suit all patients, GBT has the potential to enhance cognitive and physical recovery.

Patients' experience while transitioning from the intensive care unit to a ward

BACKGROUND

Intensive care unit (ICU) patients can experience emotional distress and post-traumatic stress disorder when they leave the ICU, also referred to as post-intensive care syndrome. A deeper understanding of what patients go through and what they need while they are transitioning from the ICU to the general ward may provide input on how to strengthen patient-centred care and, ultimately, contribute to a positive experience.

AIM

To describe the patients' experience while transitioning from the ICU to a general ward.

DESIGN

A descriptive qualitative study.

METHOD

Data were gathered through in-depth interviews and analysed using a qualitative content analysis. The qualitative study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines.

FINDINGS

Forty-eight interviews were conducted. Impact on emotional well-being emerged as a main theme, comprising four categories with six subcategories.

CONCLUSION

Transition from the ICU can be a shock for the patient, leading to the emergence of a need for information, and an impact on emotional well-being that has to be planned for carefully and addressed prior to, during, and following transition from the ICU to the general ward.

RELEVANCE TO CLINICAL PRACTICE

It is essential that nurses understand patients' experiences during transfer, identifying needs and concerns to be able to develop and implement new practices such as ICU Liaison Nurse or Nurse Outreach for the follow-up of these patients, the inclusion of a consultant mental health nurse, and the application of patient empowerment during ICU discharge.

Development of the support needs after ICU (SNAC) questionnaire

Aims

To develop a questionnaire to identify Intensive Care survivor needs at key transitions during the recovery process, and assess its validity and reliability in a group of ICU survivors.

Methods

Development of the Support Needs After ICU (SNAC) questionnaire was based on a systematic scoping review, and analysis of patient interviews (n = 22). Face and content validity were assessed by service users (n = 12) and an expert panel of healthcare professionals (n = 6). A pilot survey among 200 ICU survivors assessed recruitment at one of five different stages after ICU discharge [(1) in hospital, (2) < 6 weeks, (3) 7 weeks to 6 months, (4) 7 to 12 months, or (5) 12 to 24 months post‐hospital discharge]; to assess reliability of the SNAC questionnaire; and to conduct exploratory data analysis. Reliability was determined using Cronbach's alpha for internal consistency; intraclass correlation coefficients for test–retest reliability. We explored correlations with sociodemographic variables using Pearson's correlation coefficient; differences between questionnaire scores and patient demographics using one‐way ANOVA.

Results

The SNAC questionnaire consisted of 32 items that assessed five categories of support needs (informational, emotional, instrumental [e.g. practical physical help, provision of equipment or training], appraisal [e.g. clinician feedback on recovery] and spiritual needs). ICU survivors were recruited from Northern Ireland, England and Scotland. From a total of 375 questionnaires distributed, 202 (54%) were returned. The questionnaire had high internal consistency (0.97) and high test–retest reliability (r = 0.8) with subcategories ranging from 0.3 to 0.9.

Conclusions

The SNAC questionnaire appears to be a comprehensive, valid, and reliable questionnaire. Further research will enable more robust examination of its properties e.g. factor analysis, and establish its utility in identifying whether patients' support needs evolve over time.

Relevance to clinical practice

The SNAC questionnaire has the potential to be used to identify ICU survivors' needs and inform post‐hospital support services.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Society of Critical Care Medicine's International Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness

BACKGROUND

After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when remain unclear.

OBJECTIVES

Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for postdischarge impairments.

PARTICIPANTS

Thirty-one international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine's Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers.

DESIGN

Society of Critical Care Medicine consensus conference on post-intensive care syndrome prediction and assessment, held in Dallas, in May 2019. A systematic search of PubMed and the Cochrane Library was conducted in 2018 and updated in 2019 to complete an original systematic review and to identify pre-existing systematic reviews.

MEETING OUTCOMES

We concluded that existing tools are insufficient to reliably predict post-intensive care syndrome. We identified factors before (e.g., frailty, preexisting functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2-4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment test; Hospital Anxiety and Depression Scale; Impact of Event Scale-Revised (post-traumatic stress disorder); 6-minute walk; and/or the EuroQol-5D-5L, a health-related quality of life measure (physical function).

CONCLUSIONS

Beginning with an assessment of a patient's pre-ICU functional abilities at ICU admission, clinicians have a care coordination strategy to identify and manage impairments across the continuum. As hospital discharge approaches, clinicians should use brief, standardized assessments and compare these results to patient's pre-ICU functional abilities ("functional reconciliation"). We recommend serial assessments for post-intensive care syndrome-related problems continue within 2-4 weeks of hospital discharge, be prioritized among high-risk patients, using the identified screening tools to prompt referrals for services and/or more detailed assessments.

A qualitative study portraying nurses' perspectives on transitional care between intensive care units and hospitals wards

INTRODUCTION

The transition process from the intensive care unit (ICU) to hospital ward may impact the illness trajectory and compromise the continuity of safe care for ICU survivors. ICU and ward nurses are involved with the transition and are responsible for the quality of the transitional care.

AIM

The aim was to explore ICU and ward nurses' views on assignments in relation to patients' transition between ICU and hospital ward.

METHODS

We conducted a qualitative study with 20 semi-structured interviews with ICU nurses and ward nurses and analysed data by content analysis.

SETTING

A university hospital with 690 beds and an 11-bed mixed medical/surgical ICU.

FINDINGS

The overarching themes were (1) 'Ritual of hand over' with the categories: (a) 'Ready, able and willing', (b) 'Transfer of responsibility' and (c) 'Nice to know versus need to know' and (2) 'From lifesaving care to rehabilitative care' with the categories: (a) 'Complex care needs persist', (b) 'Fight or flight mode' and (c) '"Weaning" the family'. Nurses were highly focused on the ritual of the actual handover of the patient and discussed readiness as an indicator of quality and the feeling of passing on the responsibility. Nurses had different opinions on what useful knowledge was and thus necessary to communicate during handover. Although patients' complex care needs may not have been resolved when exiting the ICU, ward nurses had to receive patients in a setting where nurses were mostly comfortable within their own specialty - this was worrying for both type of nurses. Patients could enter the ward very exhausted and weak or in 'fight mode' and demand rehabilitation at a pace the ward was not capable of delivering. ICU nurses encouraged families to be demanding after the ICU stay, and ward nurses asked them to trust them and steep back.

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.

What can trauma patients' experiences and perspectives tell us about the perceived quality of trauma care? a qualitative study set within the UK National Health Service

The global drive for improvements in the efficiency and quality of healthcare has led to the development of frameworks to assist in defining and measuring 'good quality care'. However, such frameworks lack a systematic or meaningful definition of what 'good quality care' means from the patients' perspective. The present research provides an in-depth analysis of patients' experiences in a hospital setting from a quality of care perspective. Forty-five adults (aged 16-70) hospitalised in one of four UK NHS trusts following an unintentional injury were interviewed about their experiences of care. The findings show variability in perceived quality of care within the same hospital episode which cannot be meaningfully captured by existing frameworks. The context of trauma care (e.g. distressing nature of injury, patient vulnerability, expectations of hospitalisation and participants' interaction with different service providers) defined the care experience and the value of being 'cared for'. Participants identified some aspects of good and care which related to holistic, person-centred and personalised care beyond the medical needs. Participants discussed the value of being understood, staff thinking of their needs beyond hospitalisation, staff trying 'their best' despite constrains of current care, having their emotional needs recognised and addressed and staff competence. Patients reported also poor quality of care and 'not being cared for' by specific staff groups which they expected to fulfil this role, rushed and unsympathetic care, lack of recognition for emotional impact of injury mapped onto existing quality frameworks e.g. safety, equity, accessibility and patient-centeredness as well as quality of interaction with providers, empathetic care which extended beyond medical needs, coordination of care, and the positivity of care delivery as important dimensions of quality care with implications for their recovery. The findings have implications for quality frameworks and theoretical definitions of quality of care; they demonstrate the importance of patient experience in addition to clinical effectiveness and safety as an essential dimension of quality care. In terms of practice, the findings support the need to incorporate knowledge and training of injured adults' psychological needs, and the value of interaction with professionals as a patient defined dimension of the quality of care.

Impact of Patient and Family Involvement in Long-Term Outcomes

Surviving a critical illness can have long-term effects on both patients and families. These effects can be physical, emotional, cognitive, and social, and they affect both the patient and the family. Family members play a key role in helping their loved one recover, and this recovery process can take considerable time. Transferring out of an intensive care unit, and discharging home from a hospital, are important milestones, but they represent only the beginning of recovery and healing after a critical illness. Recognizing that these challenges exist both for patients and families is important to improve critical illness outcomes.

Engaging Patients and Families to Help Research Inform and Advance Patient and Family-Centered Care in Critical Care Medicine

Intensive care unit (ICU) patient, and family member engagement is evolving in both critical care medicine practice and research. The results of two qualitative critical care research projects led by ICU survivors and family members show how patient-partner research training can inform the critical care community of meaningful priorities in the traumatic ICU context. The resulting creation of a prioritized list of critical care research topics builds further on the construct of patient-centered care.

Patient, family and provider experiences with transfers from intensive care unit to hospital ward: a multicentre qualitative study

BACKGROUND

Transfer of patient care from an intensive care unit (ICU) to a hospital ward is often challenging, high risk and inefficient. We assessed patient and provider perspectives on barriers and facilitators to high-quality transfers and recommendations to improve the transfer process.

METHODS

We conducted semistructured interviews of participants from a multicentre prospective cohort study of ICU transfers conducted at 10 hospitals across Canada. We purposively sampled 1 patient, 1 family member of a patient, 1 ICU provider, and 1 ward provider at each of the 8 English-speaking sites. Qualitative content analysis was used to derive themes, subthemes and recommendations.

RESULTS

The 35 participants described 3 interrelated, overarching themes perceived as barriers or facilitators to high-quality patient transfers: resource availability, communication and institutional culture. Common recommendations suggested to improve ICU transfers included implementing standardized communication tools that streamline provider-provider and provider-patient communication, using multimodal communication to facilitate timely, accurate, durable and mutually reinforcing information transfer; and developing procedures to manage delays in transfer to ensure continuity of care for patients in the ICU waiting for a hospital ward bed.

INTERPRETATION

Patient and provider perspectives attribute breakdown of ICU-to-ward transfers of care to resource availability, communication and institutional culture. Patients and providers recommend standardized, multimodal communication and transfer procedures to improve quality of care.

Older Adults With Isolated Rib Fractures Do Not Require Routine Intensive Care Unit Admission

BACKGROUND

Older adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care.

MATERIALS AND METHODS

We analyzed patients ≥50 y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs.

RESULTS

Among 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry <1 L (OR 4.72, 95% CI 2.14-10.45); use of a walker (OR 2.86, 95% CI 1.29-6.34); increased chest Abbreviated Injury Scale score (AIS 3 OR 5.83, 95% CI 2.34-14.50); age ≥72 y (OR 2.68, 95% CI 1.48-4.86); and active smoking (OR 2.11, 95% CI 1.06-4.20).

CONCLUSIONS

Routine ICU admission is not necessary for most older adults with isolated rib fractures. The predictors we identified warrant prospective evaluation for development of a clinical decision rule to preclude unnecessary ICU admissions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ISRCTN14658054.

The difficulties of discharging hospice patients to care homes at the end of life: A focus group study

BACKGROUND

Discharge from inpatient palliative care units to long-term care can be challenging. In the United Kingdom, hospice inpatients move to a care home if they no longer require specialist palliative care and cannot be discharged home. There is evidence to suggest that patients and families find the prospect of such a move distressing.

AIM

To investigate the issues that arise when patients are transferred from hospice to care home at the end of life, from the perspective of the hospice multidisciplinary team.

DESIGN

A qualitative study, using thematic analysis to formulate themes from focus group discussions with hospice staff.

SETTING/PARTICIPANTS

Five focus groups were conducted with staff at five UK hospices. Participants included multidisciplinary team members involved in discharge decisions. All groups had representation from a senior nurse and doctor at the hospice, with group size between three and eight participants. All but one group included physiotherapists, occupational therapists and family support workers.

RESULTS

A major focus of group discussions concerned dilemmas around discharge. These included (1) ethical concerns (dilemmas around the decision, lack of patient autonomy and allocation of resources); (2) communication challenges; and (3) discrepancies between the ideals and realities of hospice palliative care.

CONCLUSION

Hospice palliative care unit staff find discharging patients to care homes necessary, but often unsatisfactory for themselves and distressing for patients and relatives. Further research is needed to understand patients' experiences concerning moving to care homes for end of life care, in order that interventions can be implemented to mitigate this distress.

Resilience in Survivors of Critical Illness in the Context of the Survivors' Experience and Recovery

RATIONALE

Post-intensive care syndrome (PICS), defined as new or worsening impairment in cognition, mental health, or physical function after critical illness, is an important development in survivors. Although studies to date have focused on the frequency of these impairments, fundamental questions remain unanswered regarding the survivor experience and the impact of the critical illness event on survivor resilience and recovery.

OBJECTIVES

To examine the association between resilience and neuropsychological and physical function and to contextualize these findings within the survivors' recovery experience.

METHODS

We conducted a mixed-methods pilot investigation of resilience among 43 survivors from two medical intensive care units (ICUs) within an academic health-care system. We interviewed survivors to identify barriers to and facilitators of recovery in the ICU, on the medical ward, and at home, using qualitative methods. We used a telephone battery of standardized tests to examine resilience, neuropsychological and physical function, and quality of life. We examined PICS in two ways. First, we identified how frequently survivors were impaired in one or more domains 6-12 months postdischarge. Second, we identified how frequently survivors reported that neuropsychological or physical function was worse.

MEASUREMENTS AND MAIN RESULTS

Resilience was low in 28% of survivors, normal in 63% of survivors, and high in 9% of survivors. Resilience was inversely correlated with self-reported executive dysfunction, symptoms of anxiety, depression, and post-traumatic stress disorder, difficulty with self-care, and pain (P < 0.05). PICS was present in 36 survivors (83.7%; 95% confidence interval, 69.3-93.2%), whereas 23 survivors (53.5%; 95% confidence interval, 37.6-68.8%) reported worsening of neuropsychological or physical function after critical illness. We identified challenges along the recovery path of ICU survivors, finding that physical limitations and functional dependence were the most frequent challenges experienced in the ICU, medical ward, and on return to home. Spiritual and family support facilitated recovery.

CONCLUSIONS

Resilience was inversely correlated with neuropsychological impairment, pain, and difficulty with self-care. PICS was present in most survivors of critical illness, and 54% reported neuropsychological or physical function to be worse, yet resilience was normal or high in most survivors. Survivors experienced many challenges during recovery, while spiritual and family support facilitated recovery.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

A qualitative descriptive design.

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

[Complications and monitoring standards after elective craniotomy in Germany]

BACKGROUND

The increasing endeavors to make inpatient treatment processes more effective leads to a reduction of the length of stay in hospital and minimization of postoperative monitoring. Therefore, the aim of our study was to determine potential postoperative complications for neurosurgical patients undergoing elective surgery with respect to assessment of the relevance for intensive medical care. Furthermore, our approach was compared with the standard of postoperative care of such patients in Germany.

METHODS

All 499 patients scheduled for elective craniotomy at our institute from 2010-2013 could be included corresponding to various treatment criteria for vascular diseases, such as aneurysms, arteriovenous malformation (AVM) and cavernous hemangioma as well as supratentorial and infratentorial tumors, transsphenoidally operated pituitary adenomas and stereotactic biopsies. All complications could be collated and categorized according to major and minor complications. Furthermore, a survey was conducted among 155 neurosurgical hospitals and departments with respect to the preferred postoperative monitoring strategy for the named treatment categories.

RESULTS

The numbers of major complication were in accordance with data from other studies and although minor complications (13.4% in our collective) are rarely recorded in the literature, they do however indicate an adequate postoperative inpatient monitoring. The results of the survey showed a broad preference for intensive care unit monitoring of patients undergoing elective craniotomy in Germany.

CONCLUSION

The undisputed gold standard of postoperative monitoring of neurosurgical patients undergoing elective surgery is still the intensive care unit. Although more flexible surveillance modalities are available, a cost-driven restructuring of postoperative monitoring and in particular reduction of the length of stay in hospital must be subjected to detailed scrutinization.

A tailored relocation stress intervention programme for family caregivers of patients transferred from a surgical intensive care unit to a general ward

AIMS AND OBJECTIVES

To develop and examine a relocation stress intervention programme tailored for the family caregivers of patients scheduled for transfer from a surgical intensive care unit to a general ward.

BACKGROUND

Family relocation stress syndrome has been reported to be similar to that exhibited by patients, and investigators have emphasised that nurses should make special efforts to relieve family relocation stress to maximise positive contributions to the well-being of patients by family caregivers.

DESIGN

A nonequivalent control group, nonsynchronised pretest-post-test design was adopted.

METHODS

The study subjects were 60 family caregivers of patients with neurosurgical or general surgical conditions in the surgical intensive care unit of a university hospital located in Incheon, South Korea. Relocation stress and family burden were evaluated at three times, that is before intervention, immediately after transfer and four to five days after transfer.

RESULTS

This relocation stress intervention programme was developed for the family caregivers based on disease characteristics and relocation-related needs. In the experimental group, relocation stress levels significantly and continuously decreased after intervention, whereas in the control group, a slight nonsignificant trend was observed. Family burden levels in the control group increased significantly after transfer, whereas burden levels in the experimental group increased only marginally and nonsignificantly. No significant between-group differences in relocation stress or family burden levels were observed after intervention.

CONCLUSIONS

Relocation stress levels of family caregivers were significantly decreased after intervention in the experimental group, which indicates that the devised family relocation stress intervention programme effectively alleviated family relocation stress.

RELEVANCE TO CLINICAL PRACTICE

The devised intervention programme, which was tailored to disease characteristics and relocation-related needs, may enhance the practicality and efficacy of relocation stress management and make meaningful contribution to the relief of family relocation stress, promote patient recovery and enhance the well-being of patients and family caregivers.

"I Can Remember Sort of Vivid People…but to Me They Were Plasticine." Delusions on the Intensive Care Unit: What Do Patients Think Is Going On?

INTRODUCTION

Patients who develop intensive care unit (ICU) acquired delirium stay longer in the ICU, and hospital, and are at risk of long-term mental and physical health problems. Despite guidelines for patient assessment, risk limitation, and treatment in the ICU population, delirium and associated delusions remain a relatively common occurrence on the ICU. There is considerable information in the literature describing the incidence, suspected causes of, and discussion of the benefits and side-effects of the various treatments for delirium in the ICU. But peer-reviewed patient-focused research is almost non-existent. There is therefore a very limited understanding of the reality of delusions in the intensive care unit from the patient's point of view.

METHOD

A secondary analysis of the original interviews conducted by the University of Oxford Health Experiences Research Group was undertaken to explore themes relating specifically to sleep and delirium.

RESULTS

Patients describe a liminal existence on the ICU. On the threshold of consciousness their reality is uncertain and their sense of self is exposed. Lack of autonomy in an unfamiliar environment prompts patients to develop explanations and understandings for themselves with no foothold in fact.

CONCLUSION

Patients on the ICU are perhaps more disoriented than they appear and early psychological intervention in the form of repeated orientation whilst in the ICU might improve the patient experience and defend against development of side-effects.

Qualitative research in critical care: Has its time finally come?

As clinicians, we are well acquainted with using randomised controlled trials, case-control studies and cohort studies together with p-values, odds ratios and confidence intervals to understand and improve the way in which we care for our patients. We have a degree of familiarity, trust and confidence with well-performed scientific quantitative studies in critical care and we make a judgment about our practice based on their recommendations. The same cannot be said of qualitative research, and its use accounts for only a small proportion of published studies in critical care. There are many research questions in our environment that lend themselves to a qualitative research design. Our positivistic education as doctors potentially incites distrust towards such studies and, as such, they are seldom undertaken in our units. We aim to describe and discuss the differences between quantitative and qualitative research with focus being given to common misunderstandings and misconceptions. An overview of the methods of data collection and analysis is provided with references towards published qualitative studies in critical care. Finally, we provide pragmatic and practical instruction and guidance for those wishing to undertake their own qualitative study in critical care.

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).

Improving critical care discharge summaries: a collaborative quality improvement project using PDSA

Around 110,000 people spend time in critical care units in England and Wales each year. The transition of care from the intensive care unit to the general ward exposes patients to potential harms from changes in healthcare providers and environment. Nurses working on general wards report anxiety and uncertainty when receiving patients from critical care. An innovative form of enhanced capability critical care outreach called 'iMobile' is being provided at King's College Hospital (KCH). Part of the remit of iMobile is to review patients who have been transferred from critical care to general wards. The iMobile team wished to improve the quality of critical care discharge summaries. A collaborative evidence-based quality improvement project was therefore undertaken by the iMobile team at KCH in conjunction with researchers from King's Improvement Science (KIS). Plan, Do, Study, Act (PDSA) methodology was used. Three PDSA cycles were undertaken. Methods adopted comprised: a scoping literature review to identify relevant guidelines and research evidence to inform all aspects of the quality improvement project; a process mapping exercise; informal focus groups / interviews with staff; patient story-telling work with people who had experienced critical care and subsequent discharge to a general ward; and regular audits of the quality of both medical and nursing critical care discharge summaries. The following behaviour change interventions were adopted, taking into account evidence of effectiveness from published systematic reviews and considering the local context: regular audit and feedback of the quality of discharge summaries, feedback of patient experience, and championing and education delivered by local opinion leaders. The audit results were mixed across the trajectory of the project, demonstrating the difficulty of sustaining positive change. This was particularly important as critical care bed occupancy and through-put fluctuates which then impacts on work-load, with new cohorts of staff regularly passing through critical care. In addition to presenting the results of this quality improvement project, we also reflect on the lessons learned and make suggestions for future projects.

Maternal critical care: what can we learn from patient experience? A qualitative study

OBJECTIVE

For every maternal death, nine women develop severe maternal morbidity. Many of those women will need care in an intensive care unit (ICU) or high dependency unit (HDU). Critical care in the context of pregnancy poses distinct issues for staff and patients, for example, with breastfeeding support and separation from the newborn. This study aimed to understand the experiences of women who experience a maternal near miss and require critical care after childbirth.

SETTING

Women and some partners from across the UK were interviewed as part of a study of experiences of near-miss maternal morbidity.

DESIGN

A qualitative study, using semistructured interviews.

PARTICIPANTS

A maximum variation sample was recruited of 35 women and 11 partners of women who had experienced a severe maternal illness, which without urgent medical attention would have led to her death. 18 of the women were admitted to ICU or HDU.

RESULTS

The findings are presented in three themes: being in critical care; being a new mother in critical care; transfer and follow-up after critical care. The study highlights the shock of requiring critical care for new mothers and the gulf between their expectations of birth and what actually happened; the devastation of being separated from their baby, how valuable access to their newborn was, if possible, and the importance of breast feeding; the difficulties of transfer and the need for more support; the value of follow-up and outreach to this population of critical care patients.

CONCLUSIONS

While uncommon, critical illness in pregnancy can be devastating for new mothers and presents a challenge for critical care and maternity staff. This study provides insights into these challenges and recommendations for overcoming them drawn from patient experiences.

A scoping review of patient discharge from intensive care: opportunities and tools to improve care

BACKGROUND

We conducted a scoping review to systematically review the literature reporting patient discharge from ICUs, identify facilitators and barriers to high-quality care, and describe tools developed to improve care.

METHODS

We searched Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. Data were extracted on the article type, study details for research articles, patient population, phase of care during discharge, and dimensions of health-care quality.

RESULTS

From 8,154 unique publications we included 224 articles. Of these, 131 articles (58%) were original research, predominantly case series (23%) and cohort (16%) studies; 12% were narrative reviews; and 11% were guidelines/policies. Common themes included patient and family needs/experiences (29% of articles) and the importance of complete and accurate information (26%). Facilitators of high-quality care included provider-patient communication (30%), provider-provider communication (25%), and the use of guidelines/policies (29%). Patient and family anxiety (21%) and limited availability of ICU and ward resources (26%) were reported barriers to high-quality care. A total of 47 tools to facilitate patient discharge from the ICU were identified and focused on patient evaluation for discharge (29%), discharge planning and teaching (47%), and optimized discharge summaries (23%).

CONCLUSIONS

Common themes, facilitators and barriers related to patient and family needs/experiences, communication, and the use of guidelines/policies to standardize patient discharge from ICU transcend the literature. Candidate tools to improve care are available; comparative evaluation is needed prior to broad implementation and could be tested through local quality-improvement programs.

Clinical validity of a relocation stress scale for the families of patients transferred from intensive care units

AIMS AND OBJECTIVES

This study was conducted to develop a family relocation stress scale by modifying the Son's Relocation Stress Syndrome Scale, to examine its clinical validity and reliability and to confirm its suitability for measuring family relocation stress.

BACKGROUND

The transfer of ICU patients to general wards is a significant anxiety-producing event for family members. However, no relocation stress scale has been developed specifically for families.

DESIGN

A nonexperimental, correlation design was adopted.

METHODS

The study subjects were 95 family members of 95 ICU patients at a university hospital located in Incheon, South Korea. Face and construct validities of the devised family relocation stress scale were examined. Construct validity was examined using factor analysis and by using a nomological validity test. Reliability was also examined.

RESULTS

Face and content validity of the scale were verified by confirming that its items adequately measured family relocation stress. Factor analysis yielded four components, and the total variance explained by these four components was 63·0%, which is acceptable. Nomological validity was well supported by significant relationships between relocation stress and degree of preparation for relocation, patient self-care ability, family burden and satisfaction with the relocation process. The devised scale was also found to have good reliability.

CONCLUSIONS

The family relocation stress scale devised in this study was found to have good validity and reliability, and thus, is believed to offer a means of assessing family relocation stress.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study provide a reliable and valid assessment tool when nurses prepare families for patient transfer from an ICU to a ward setting, and may also provide useful information to those developing an intervention programme for family relocation stress management.

Changing support needs of survivors of complex critical illness and their family caregivers across the care continuum: a qualitative pilot study of Towards RECOVER

INTRODUCTION

Survivors of complex critical illness and their family caregivers require support during their recovery, rehabilitation, and return to community living; however, the nature of these supports and how they may change over time remain unclear. Using the Timing It Right framework as a conceptual guide, this qualitative pilot study explored survivors' and caregivers' needs during the episode of critical illness through their return to independent living.

METHODS

Five survivors and seven family caregivers were recruited and consented from the main Towards RECOVER pilot study, designed to characterize the long term outcomes of survivors of the ICU who have been mechanically ventilated for more than one week. Using the Timing It Right framework, we prospectively conducted qualitative interviews to explore participants' experiences and needs for information, emotional support, and training at 3, 6, 12, and 24 months after intensive care unit (ICU) discharge. We completed 26 interviews, which were audio recorded, professionally transcribed, checked for accuracy, and analyzed using framework methodology.

RESULTS

In this small pilot sample, caregiver and patient perspectives were related and, therefore, are presented together. We identified 1 overriding theme: survivors do not experience continuity of medical care during recovery after critical illness. Three subthemes highlighted the following: (1) informational needs change across the care continuum, (2) fear and worry exist when families do not know what to expect, and (3) survivors transition from dependence to independence.

CONCLUSIONS

Interventions designed to improve family outcomes after critical illness should address both survivors' and caregivers' support needs as they change across the illness and recovery trajectory. Providing early intervention and support and clarifying expectations for transitions in care and recovery may decrease fears of the unknown for both caregivers and survivors. Ongoing family-centered follow-up programs may also help survivors regain independence and help caregivers manage their perceived responsibility for the patients' health. Using these insights for intervention development could ultimately improve long-term outcomes for both survivors and caregivers.

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

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

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

OBJECTIVES

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

DESIGN

A pragmatic prospective cohort study.

SETTING

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

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

AIMS

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

BACKGROUND

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

FINDINGS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

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

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

OBJECTIVE

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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