What patients think about ICU follow-up services: a qualitative study

"The Psychiatric Domain of Post-Intensive Care Syndrome: A Review for the Intensivist"

Post-intensive care syndrome (PICS) is a clinical syndrome characterized by new or worsening changes in mental health, cognition, or physical function that persist following critical illness. The psychiatric domain of PICS encompasses new or worsened psychiatric burdens following critical illness, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many of the established predisposing and precipitating factors for the psychiatric domain of PICS are commonly found in the setting of critical illness, including mechanical ventilation (MV), exposure to sedating medications, and physical restraint. Importantly, previous psychiatric history is a strong risk factor for the development of the psychiatric domain of PICS and should be considered when screening patients to diagnose psychiatric impairment and interventions. Delirium has been associated with psychiatric symptoms following ICU admission, therefore prevention warrants careful consideration. Dexmedetomidine has been shown to have the lowest risk for development of delirium when compared to other sedatives and has been the only sedative studied in relation to the psychiatric domain of PICS. Nocturnal dexmedetomidine and intensive care unit (ICU) diaries have been associated with decreased psychiatric burden after ICU discharge. Studies evaluating the impact of other intra-ICU practices on the development of the psychiatric domain of PICS, including the ABCDEF bundle, depth of sedation, and daily spontaneous awakening trials, have been limited and inconclusive. The psychiatric domain of PICS is difficult to treat and may be less responsive to multidisciplinary post-discharge programs and targeted interventions than the cognitive and physical domains of PICS. Given the high morbidity associated with the psychiatric domain of PICS, intensivists should familiarize themselves with the risk factors and intra-ICU interventions that can mitigate this important and under-recognized condition.

Experiences with hospital-to-home transitions: perspectives from patients, family members and healthcare professionals. A systematic review and meta-synthesis of qualitative studies

PURPOSE

Multiple studies have explored the needs and experiences of patients, family members, and healthcare professionals regarding hospital-to-home transitions. Our study aimed to identify, critically appraise, and summarize these studies in a qualitative meta-synthesis.

MATERIALS AND METHODS

Medline, CINAHL and Embase were systematically searched to identify eligible articles from inception to June 2024. Qualitative studies were included and critically appraised using the Critical Appraisal Skills Program. Insufficient-quality papers were excluded. We performed a meta-synthesis following (1) open coding by two independent researchers and (2) discussing codes during reflexivity meetings.

RESULTS

Ninety-eight studies were appraised, of which 53 were included. We reached thematic saturation, four themes were constructed: (1) care coordination and continuity, (2) communication, (3) patient and family involvement, and (4) individualized support and information exchange. For patients and families, tailored information and support are prerequisites for a seamless transition and an optimal recovery trajectory after hospital discharge. It is imperative that healthcare professionals communicate effectively within and across care settings to ensure multidisciplinary collaboration and care continuity.

CONCLUSIONS

This study identifies essential elements of optimal transitional care. These findings could be supportive to researchers and healthcare professionals when (re)designing transitional care interventions to ensure care continuity after hospital discharge.

A shift towards targeted post-ICU treatment: Multidisciplinary care for cardiac arrest survivors

Intensive Care Unit (ICU) survivorship comprises a burgeoning area of critical care medicine, largely due to our improved understanding of and concern for patients' recovery trajectory, and efforts to mitigate the post-acute complications of critical illness. Expansion of care beyond hospitalization is necessary, yet evidence for post-ICU clinics remains limited and mixed, as both interventions and target populations studied to date are too heterogenous to meaningfully demonstrate efficacy. Here, we briefly present the existing evidence and limitations related to post-ICU clinics, identify cardiac arrest survivors as a unique ICU subpopulation warranting further investigation and treatment, and propose a clinical framework that addresses the multifaceted needs of this well-defined patient population.

Post-intensive care syndrome screening: a French multicentre survey

BACKGROUND

Post-intensive care syndrome (PICS), defined as physical, cognitive, and mental-health symptoms persisting long after intensive-care-unit (ICU) discharge, is increasingly recognised as a healthcare priority. Data on screening for PICS are sparse. Our objective here was to describe post-ICU screening in France, with special attention to visit availability and evaluations done during visits.

METHODS

We conducted an online multicentre survey by emailing an anonymous 43-item questionnaire to French ICUs. For each ICU, a single survey was sent to either the head or the intensivist in charge of follow-up visits.

RESULTS

Of 252 ICUs invited to participate, 161 (63.9%) returned the completed survey. Among them, 46 (28.6%) offered follow-up visits. Usually, a single visit led by an intensivist was scheduled 3 to 6 months after ICU discharge. Approximately 50 patients/year/ICU, that is, about 5% of admitted patients, attended post-ICU visits. The main criteria used to select patients for follow-up were ICU stay and/or invasive mechanical ventilation duration longer than 48 h, cardiac arrest, septic shock, and acute respiratory distress syndrome. Among ICUs offering visits, 80% used validated instruments to screen for PICS. Of the 115 ICUs not offering follow-up, 50 (43.5%) indicated an intention to start follow-up within the next year. The main barriers to offering follow-up were lack of available staff and equipment or not viewing PICS screening as a priority. Half the ICUs offering visits worked with an established network of post-ICU care professionals, and another 17% were setting up such a network. Obstacles to network creation were lack of interest among healthcare professionals and lack of specific training in PICS.

CONCLUSION

Only a small minority of ICU survivors received follow-up designed to detect PICS. Less than a third of ICUs offered follow-up visits but nearly another third planned to set up such visits within the next year. Recommendations issued by French health authorities in 2023 can be expected to improve the availability and standardisation of post-ICU follow-up.

Barriers and facilitators to offering post-intensive care follow-up services from the perspective of critical care professionals: A qualitative study

BACKGROUND

Various programmes and models for post-intensive care unit (ICU) follow-up services have been developed worldwide. In China, post-ICU follow-up remains in the exploratory stage and little is known regarding the appropriate form and challenges of implementation, which need to be further explored.

AIM

This study aimed to explore and describe the barriers to and facilitators of post-ICU follow-up services from the perspective of critical care professionals.

DESIGN

This was a descriptive qualitative study. Semi-structured interviews were conducted with 21 health care workers whose units had offered ICU survivors different forms of follow-up services; the data were analysed by qualitative content analysis during August 2022 and December 2022.

SETTING

The study was conducted at 14 ICUs in 11 tertiary hospitals in Shanghai, China.

FINDINGS

Seventeen subthemes were extracted as barriers and facilitators in the follow-up of ICU survivors. In the initiating process, the barriers included the restriction of decision-making rights and scope of practice, indifferent attitude towards survivors and repeated work. The facilitators included admitted significance, the needs of ICU survivors, the conscientiousness of professionals and the pioneers and leadership support. In the implementation process, lack of confidence, lack of cooperation in medical consortium, distrusted relationships, restrictions of medical insurance, ageing problems and insufficient human resources acted as barriers, whereas lessons learned, positive feedback and digital support served as facilitators. Furthermore, recommendations and tips were identified for offering follow-up services.

CONCLUSION

Medical personnel can better utilize available resources and develop strategies to overcome constraints by gaining insights into the abovementioned barriers and facilitators. The findings of this study can provide a useful reference for structured and systematic follow-ups to ameliorate post-intensive care syndrome in low- and middle-income countries.

RELEVANCE TO CLINICAL PRACTICE

Publicity and educational measures play a crucial role in enhancing the awareness of survivors and the consensus of health care professionals from medical consortium regarding impairments after critical care. Leadership and policy support can address numerous obstacles to guiding follow-up services.

Adherence with post-hospitalization follow-up after pediatric critical illness due to respiratory failure

BACKGROUND

Adherence with follow-up appointments after a pediatric intensive care unit (PICU) admission is likely a key component in managing post-PICU sequalae. However, prior work on PICU follow-up adherence is limited. The objective of this study is to identify hospitalization characteristics, discharge child health metrics, and follow-up characteristics associated with full adherence with recommended follow-up at a quaternary care center after a PICU admission due to respiratory failure.

METHODS

We conducted a retrospective cohort study of patients ≤ 18 years with respiratory failure admitted between 1/2013-12/2014 to a quaternary care PICU. Post-hospitalization full adherence with recommended follow-up in the two years post discharge (1/2013-3/2017) at the quaternary care center was quantified and compared by demographics, baseline child health metrics, hospitalization characteristics, discharge child health metrics, and follow-up characteristics in bivariate and multivariate analyses. Patients were dichotomized into being non-adherent with follow-up (patients who attended less than 100% of recommended appointments at the quaternary care center) and fully adherent (patients who attended 100% of recommended appointments at the quaternary care center).

RESULTS

Of 155 patients alive at hospital discharge, 140 (90.3%) were recommended to follow-up at the quaternary care center. Of the 140 patients with recommended follow-up at the quaternary care center, 32.1% were non-adherent with follow-up and 67.9% were fully adherent. In a multivariable logistic regression model, each additional recommended unique follow-up appointment was associated with lower odds of being fully adherent with follow-up (OR 0.74, 95% CI 0.60-0.91, p = 0.005), and each 10% increase in the proportion of appointments scheduled before discharge was associated with higher odds of being fully adherent with follow-up (OR 1.02, 95% CI 1.01-1.03, p = 0.004).

CONCLUSIONS

After admission for acute respiratory failure, only two-thirds of children were fully adherent with recommended follow-up at a quaternary care center. Our findings suggest that limiting the recommended follow-up to only key essential healthcare providers and working to schedule as many appointments as possible before discharge could improve follow-up adherence. However, a better understanding of the factors that lead to non-adherence with follow-up appointments is needed to inform broader system-level approaches could help improve PICU follow-up adherence.

Models of intensive care unit follow-up care and feasibility of intervention delivery: A systematic review

BACKGROUND

The optimal model of outpatient intensive care unit (ICU) follow-up care remains uncertain, and there is limited evidence of benefit.

RESEARCH QUESTION

The objective of this research is to describe existing models of outpatient ICU follow-up care, quantify participant recruitment and retention, and describe facilitators of patient engagement.

STUDY DESIGN & METHODS

A systematic search of the MEDLINE and EMBASE databases was undertaken in June 2021. Two independent reviewers screened titles, abstracts, and full texts against eligibility criteria. Studies of adults with any outpatient ICU follow-up were included. Studies were excluded if published before 1990, not published in English, or of paediatric patients. Quantitative data were extracted using predefined data fields. Key themes were extracted from qualitative studies. Risk of bias was assessed.

RESULTS

A total of 531 studies were screened. Forty-seven studies (32 quantitative and 15 qualitative studies) with a total of 5998 participants were included. Of 33 quantitative study interventions, the most frequently reported model of care was in-person hospital-based interventions (n = 27), with 10 hybrid (part in-hospital, part remote) interventions. Literature was limited for interventions without hospital attendance (n = 6), including telehealth and diaries. The median ranges of rates of recruitment, rates of intervention delivery, and retention to outcome assessment for hospital-based interventions were 51.5% [24-94%], 61.9% [8-100%], and 52% [8.1-82%], respectively. Rates were higher for interventions without hospital attendance: 82.6% [60-100%], 68.5% [59-89%], and 75% [54-100%]. Facilitators of engagement included patient-perceived value of follow-up, continuity of care, intervention accessibility and flexibility, and follow-up design. Studies had a moderate risk of bias.

INTERPRETATION

Models of post-ICU care without in-person attendance at the index hospital potentially have higher rates of recruitment, intervention delivery success, and increased participant retention when compared to hospital-based interventions.

PROSPERO REGISTRATION

CRD42021260279.

The impact of critical illness on patients' physical function and recovery: An explanatory mixed-methods analysis

OBJECTIVES

To determine how the perception of physical function 6-months following critical illness compares to objectively measured function, and to identify key concerns for patients during recovery from critical illness.

RESEARCH METHODOLOGY AND DESIGN

A nested convergent parallel mixed methods study assessed physical function during a home visit 6-months following critical illness, with semi-structured interviews conducted at the same time.

SETTING

Participants were recruited from two hospitals at one healthcare network in Melbourne, Australia from September 2017 to October 2018 with follow-up data completed in April 2019.

MAIN OUTCOME MEASURES

Physical function was assessed through four objective outcomes: the functional independence measure, six-minute walk test, functional reach test, and grip strength. Semi structured interviews focused on participants function, memories of the intensive care and hospital stay, assistance required on discharge, ongoing limitations, and the recovery process.

FINDINGS

Although many participants (12/20, 60%) stated they had recovered from their critical illness, 14 (70%) had function below expected population norms. Decreased function on returning home was commonly reported, although eleven participants were described as independent and safe for discharge from hospital-based staff. The importance of family and social networks to facilitate discharge was highlighted, however participants often described wanting more support and issues accessing services. The effect of critical illness on the financial well-being of the family network was confirmed, with difficulties accessing financial support identified.

CONCLUSION

Survivors of critical illness perceived a better functional state than measured, but many report new limitations 6-months after critical illness. Family and friends play a crucial role in facilitating transition home and providing financial support.

IMPLICATIONS FOR CLINICAL PRACTICE

Implementation of specific discharge liaison personnel to provide education, support and assist the transition from hospital-based care to home, particularly in those without stable social supports, may improve the recovery process for survivors of critical illness.

Critical illness survivors' experiences of attending an intensive care unit follow-up service: a systematic review protocol

OBJECTIVE

The objective of this review is to explore critical illness survivors' experiences of attending an intensive care unit (ICU) follow-up service.

INTRODUCTION

A significant proportion of critical illness survivors will require ICU follow-up care to support adverse symptoms in health domains, including cognition, mental health, and physical and social function. While there is consensus on the need for ICU follow-up services, systematic reviews to date have not identified any significant impact of ICU follow-up services on clinical health outcomes. An understanding of survivors' experiences of attending an ICU follow-up service may improve the effectiveness and design of such services.

INCLUSION CRITERIA

This review will include studies that explore the experiences of adult ( 18 years of age) critical illness survivors who attended an ICU follow-up service following discharge from an ICU, regardless of the admitting diagnosis or ICU length of stay.

METHODS

This review will be conducted in line with the JBI methodological framework for qualitative systematic reviews. Electronic databases, including MEDLINE, CINAHL, PsycINFO, Embase, and Web of Science Core Collection, will be searched to identify relevant studies for inclusion in the review. Studies will be screened by 2 independent reviewers. Critical appraisal, data extraction, and data synthesis will be completed by 2 independent reviewers using a meta-aggregation method for data synthesis. Confidence in the research findings will be assessed and assigned a ConQual score.

REVIEW REGISTRATION

PROSPERO CRD42023404585.

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

Background

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

Methods

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

Results

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

Conclusion

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

Patient and caregiver experiences with a telemedicine intensive care unit recovery clinic

BACKGROUND

Intensive Care Unit Recovery Clinics (ICU-RCs) were founded to address post-intensive care syndrome among ICU survivors. Telemedicine ICU-RCs may facilitate access for more ICU survivors, however, patient and caregiver experiences with telemedicine ICU-RCs have not been explored qualitatively.

OBJECTIVE

To explore patient and informal caregiver experiences with a telemedicine ICU-RC.

METHODS

Our qualitative exploratory cross-sectional study was guided by qualitative description methodology. Telemedicine ICU-RC visits were conducted at 3- and 12-weeks post-discharge following critical illness. Patients, and caregivers when available, met with an ICU pharmacist, ICU physician, and a neuropsychologist via Zoom. Thereafter, we conducted qualitative (1:1) telephone interviews with 14 patients and 12 caregivers recruited purposefully. Data were analyzed using conventional content analysis.

RESULTS

Five themes were identified: (1) general impressions of the intervention; (2) intervention organization and delivery; (3) intervention substance; (4) caregiver participation; and (5) ways to improve the intervention. Participants found the telemedicine delivery acceptable, convenient, time-saving, and conducive to thorough discussions. Participants appreciated the information, reassurance, and validation. Attention to mental health during the visits was strongly endorsed. Caregiver involvement depended on patient self-management and technical ability. Suggestions included scheduling a 1-week post-discharge visit, more follow-up visits, and individualizing content for in-depth discussions, including mental health evaluation.

CONCLUSIONS

The study results enhance the understanding of patient and caregiver experiences with a telemedicine ICU-RC. Participants' narratives helped to formulate recommendations to improve telemedicine ICU-RC delivery and content. Acceptability of this intervention indicates the potential for wider implementation of telemedicine ICU-RCs to reach more ICU survivors.

Organization, feasibility and patient appreciation of a follow-up consultation in surgical critically ill patients with favorable baseline quality of life and prolonged ICU-stay: a pilot study

OBJECTIVES

Intensive care unit (ICU) survivors are often left with impairments in physical, mental and cognitive functioning (Post-Intensive Care Syndrome (PICS)). We evaluated the organization, the feasibility for caregivers and patients and the patients' appreciation of a post-ICU consultation aiming to detect these PICS-symptoms.

METHODS

A single-center prospective observational pilot study was conducted during an 18 month-period in the surgical ICU of a tertiary care hospital. Consecutive adult patients with an ICU-stay of ≥8 days and a favorable baseline quality of life (utility index ≥0.6 on EQ-5D-3 L) were eligible for inclusion. A post-ICU follow-up consultation consisting of a structured interview was scheduled 3 months after hospital discharge. Characteristics of the consultation (CG) and no consultation group (NCG) were compared. P-values <0.05 were considered significant.

RESULTS

Of 133 eligible patients, 85 (64%) consented for the study and 42 (49%) attended the consultation. A total of 148 phone calls were made to schedule the consultations. Consultations took a median of 68 (61-74) minutes. Compared to CG-patients, NCG-patients were more often discharged to a care facility (P = 0.003) and had more problems with mobility (P = 0.014), self-care (P < 0.001) and usual activities (P = 0.005) after 3 months. At least one PICS-related problem was documented in all patients in the CG and NCG. Thirty-four CG-patients (81%) appreciated the initiative.

CONCLUSION

Organizing an ICU-follow-up consultation was difficult and feasibility was low, but most attending patients appreciated the initiative. Better developed structures for ICU-follow-up are needed in view of the high number of PICS-related problems documented.

Outpatient Mental Health Follow-up and Recurrent Self-harm and Suicide Among Patients Admitted to the ICU for Self-harm: A Population-based Cohort Study

BACKGROUND

Patients surviving an ICU admission for deliberate self-harm are at high risk of recurrent self-harm or suicide after discharge. It is unknown whether mental health follow-up after discharge (with either a family physician or psychiatrist) reduces this risk.

RESEARCH QUESTION

What is the association between mental health follow-up after discharge and recurrent self-harm among patients admitted to the ICU for intentional self-harm?

STUDY DESIGN AND METHODS

Population-based cohort study of consecutive adults (≥ 18 years of age) from Ontario, Canada, who were admitted to ICU because of intentional self-harm between 2009 and 2017. We categorized patients according to follow-up, with 'early follow-up' indicating 1 to 21 days after discharge, 'late follow-up' indicating 22 to 60 days after discharge, and 'no follow-up' indicating no follow-up within 60 days of discharge. We conducted analyses using a cause-specific extended Cox regression model to account for varying time for mental health follow-up relative to the outcomes of interest. The primary outcome was recurrent ICU admission for self-harm within 1 year of discharge.

RESULTS

We included 9,569 consecutive adults admitted to the ICU for deliberate self-harm. Compared with receiving no mental health follow-up, both early follow-up (hazard ratio [HR], 1.37; 95% CI, 1.07-1.75) and late follow-up (HR, 1.69; 95% CI, 1.22-2.35) were associated with increased risk in recurrent ICU admission for self-harm. As compared with no follow-up, neither early follow-up (HR, 1.10; 95% CI, 0.70-1.73) nor late follow-up (HR, 1.54; 95% CI, 0.84-2.83) were associated with increased risk of death by suicide.

INTERPREATION

Among adults admitted to the ICU for deliberate self-harm, mental health follow-up after discharge was not associated with reduced risk of recurrent ICU admission for self-harm or death resulting from suicide, and patients seeking outpatient follow-up may be those at highest risk of these outcomes. Future research should focus on additional and novel methods of risk mitigation in this vulnerable population.

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.

Intensive care-related loss of quality of life and autonomy at 6 months post-discharge: Does COVID-19 really make things worse?

Objective

To compare old patients hospitalized in ICU for respiratory distress due to COVID-19 with old patients hospitalized in ICU for a non-COVID-19-related reason in terms of autonomy and quality of life.

Design

Comparison of two prospective multi-centric studies.

Setting

This study was based on two prospective multi-centric studies, the Senior-COVID-Rea cohort (COVID-19-diagnosed ICU-admitted patients aged over 60) and the FRAGIREA cohort (ICU-admitted patients aged over 70).

Patients

We included herein the patients from both cohorts who had been evaluated at day 180 after admission (ADL score and quality of life).

Interventions

None.

Measurements and main results

A total of 93 COVID-19 patients and 185 control-ICU patients were included. Both groups were not balanced on age, body mass index, mechanical ventilation, length of ICU stay, and ADL and SAPS II scores. We modeled with ordered logistic regression the influence of COVID-19 on the quality of life and the ADL score. After adjustment on these factors, we observed COVID-19 patients were less likely to have a loss of usual activities (aOR [95% CI] 0.47 [0.23; 0.94]), a loss of mobility (aOR [95% CI] 0.30 [0.14; 0.63]), and a loss of ADL score (aOR [95% CI] 0.30 [0.14; 0.63]). On day 180, 52 (56%) COVID-19 patients presented signs of dyspnea, 37 (40%) still used analgesics, 17 (18%) used anxiolytics, and 14 (13%) used antidepressant.

Conclusions

COVID-19-related ICU stay was not associated with a lower quality of life or lower autonomy compared to non-COVID-19-related ICU stay.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03958-6.

The Impact of an Intensivist-Led Critical Care Transition Program

Objective: Evaluate the impact of a post-discharge critical care transition program (CTP) on intensive care unit (ICU) readmission, in-hospital mortality, and six-month survival.

Methods: This was a prospective observational, single-center study, with a before-after design, in a critical care department in a tertiary hospital in Northern Portugal. Critically ill patients with ICU stay > 48 h or intermediate care stay >72 h or tracheostomized patients were included in the program. Historic controls included critically ill patients admitted in the six months prior to program implementation. The follow-up visit included a medical evaluation by an intensivist and a meeting with the attending physician. The primary outcome was critical care department readmission. Secondary outcomes were mortality at hospital discharge, 28-day, and six-month mortality. The readmission rate was compared between groups. Multivariate analysis and Kaplan-Meyer survival analysis were used to evaluate survival benefits.

Results: Between September 2020 and March 2021, 132 patients were included in the CTP. The Control group included 196 patients. The intensivist’s assessment led to management change in 15.1% of patients. The CTP group had a non-significant lower readmission rate (0.8% vs. 4.1%; p=0.09). Multivariate analysis showed a benefit for the CTP regarding in-hospital, 28-day, and six-month mortality. Kaplan-Meyer survival analysis showed improved survival in the CTP group.

Conclusions: The CTP reduced, non-significantly, the readmission rate, and significantly improved in-hospital and six-month mortality. Further analyses are needed to improve inclusion criteria and better allocate human resources.

Experiences, opinions and expectations of health care providers towards an intensive care unit follow-up clinic: Qualitative study and online survey

OBJECTIVES

Independent of the underlying disease, intensive care unit survivors often suffer from cognitive, physical and mental impairments, also known as post-intensive care syndrome (PICS). Specific follow-up services are recommended for these patients. This study aims to capture the perspectives of health care providers on the development of the first intensive care unit follow-up-clinic in Germany.

RESEARCH METHODOLOGY

A qualitative study with six focus groups (n = 41) and six expert interviews, followed by a quantitative survey was conducted, involving nine different professions. Qualitative and quantitative data were analysed using thematic analysis and descriptive statistics, respectively.

FINDINGS

Participants described aftercare of former intensive care unit patients as complex and appreciated the idea of an intensive care unit follow-up clinic to improve continuity of care and multidisciplinary collaboration. The favoured model combined diagnostics and targeted referral of patients to specialists and therapists with the provision of information. In the survey, participants disagreed on how to implement this referral system but agreed that assessments should be multidimensional.

CONCLUSION

The necessity of and important criteria for the design of an intensive care unit follow-up clinic were identified. We will integrate these data with further evidence to develop a concept for a complex intervention.

The effects of intensive care unit-initiated transitional care interventions on elements of post-intensive care syndrome: A systematic review and meta-analysis

OBJECTIVE

The aim of the study was to assess the effectiveness of intensive care unit (ICU)-initiated transitional care interventions for patients and families on elements of post-intensive care syndrome (PICS) and/or PICS-family (PICS--F).

REVIEW METHOD USED

This is a systematic review and meta-analysis SOURCES: The authors searched in biomedical bibliographic databases including PubMed, Embase (OVID), CINAHL Plus (EBSCO), Web of Science, and the Cochrane Library and included studies written in English conducted up to October 8, 2020.

REVIEW METHODS

We included (non)randomised controlled trials focussing on ICU-initiated transitional care interventions for patients and families. Two authors conducted selection, quality assessment, and data extraction and synthesis independently. Outcomes were described using the three elements of PICS, which were categorised into (i) physical impairments (pulmonary, neuromuscular, and physical function), (ii) cognitive impairments (executive function, memory, attention, visuo-spatial and mental processing speed), and (iii) psychological health (anxiety, depression, acute stress disorder, post-traumatic stress disorder, and depression).

RESULTS

From the initially identified 5052 articles, five studies were included (i.e., two randomised controlled trials and three nonrandomised controlled trials) with varied transitional care interventions. Quality among the studies differs from moderate to high risk of bias. Evidence from the studies shows no significant differences in favour of transitional care interventions on physical or psychological aspects of PICS-(F). One study with a nurse-led structured follow-up program showed a significant difference in physical function at 3 months.

CONCLUSIONS

Our review revealed that there is a paucity of research about the effectiveness of transitional care interventions for ICU patients with PICS. All, except one of the identified studies, failed to show a significant effect on the elements of PICS. However, these results should be interpreted with caution owing to variety and scarcity of data.

PROSPERO REGISTRATION

CRD42020136589 (available via https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020136589).

Posthospitalization follow-up recommendations after pediatric critical illness due to respiratory failure

OBJECTIVES

To characterize the recommended posthospitalization follow-up by provider type and location after a pediatric critical illness due to respiratory failure.

WORKING HYPOTHESIS

After pediatric critical illness due to respiratory failure, patients will not have a standard follow-up pattern with regard to provider type or follow-up location.

STUDY DESIGN

A retrospective cohort study.

SUBJECT SELECTION

Children, 18 years or younger, admitted to a quaternary care pediatric intensive care unit with respiratory failure between January 1, 2013 and December 31, 2014.

METHODOLOGY

For eligible patients, recommendations for posthospitalization follow-up including provider type (primary care and specialty care) and location (community care center vs. tertiary care center) were characterized from medical chart review. Recommendations were examined for all patients and two patient subgroups (patients who received extracorporeal membrane oxygenation and patients with tracheostomy).

RESULTS

Of 155 patients alive at hospital discharge, the median age was 2.1 (interquartile range, 0.7-10.6) years. Eighty percent of patients were instructed to follow-up with a primary care provider but only 52.9% with a pulmonologist. We found 10 unique follow-up patterns between provider location (community care center, tertiary care center, or both) and global provider type (primary care versus specialty care). Primary care follow-up was recommended more often at community locations (74.2%), whereas specialty care was more often recommended at tertiary care centers (68.6%).

CONCLUSIONS

Our study findings demonstrate significant variability in the recommendations for follow-up by provider type and location after hospitalization for acute respiratory failure and highlight areas for improvement in follow-up care after pediatric critical illness.

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

AIMS AND OBJECTIVE

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

BACKGROUND

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Older patients' recovery following intensive care: A follow-up study with the RAIN questionnaire

The aim was to investigate older patient recovery (65 years+) up to two years following discharge from an intensive care unit (ICU) using the Recovery After Intensive Care (RAIN) instrument and to correlate RAIN with the Hospital Anxiety and Depression Scale (HAD).

METHODS

An explorative and descriptive longitudinal design was used. Eighty-two patients answered RAIN and HAD at least twice following discharge. Demographic and clinical data were collected from patient records.

RESULTS

Recovery after the ICU was relatively stable and good for older patients at the four data collection points. There was little variation on the RAIN subscales over time. The greatest recovery improvement was found in existential ruminations from 2 to 24 months. A patient that could look forward and those with supportive relatives had the highest scores at all four measurements. Having lower financial situation was correlated to poorer recovery and was significant at 24 months. The RAIN and HAD instruments showed significant correlations, except for the revaluation of life subscale, which is not an aspect in HAD.

CONCLUSION

The RAIN instrument shows to be a good measurement for all dimensions of recovery, including existential dimensions, which are not covered by any other instrument.

Opt-in or opt-out health-care communication? A cross-sectional study

BACKGROUND

Patients need medication and medical condition-related information to better self-manage their health. Health-care professionals (HCPs) should be able to actively provide information outside of one-on-one consultations; however, patient consent may be required.

OBJECTIVE

To investigate the Australian public's preferences, and factors that may influence their preferences, towards an opt-in versus an opt-out approach to health communication.

DESIGN

A cross-sectional study using a structured questionnaire administered via Computer-Assisted Telephone Interviewing.

SETTING AND PARTICIPANTS

Participants across Australia who were adults, English-speaking and had a long-term medical condition.

MAIN OUTCOME MEASURES

Preferences for opt-in vs opt-out approach to receiving follow-up tailored information.

RESULTS

A total of 8683 calls were made to achieve the required sample size of 589 completed surveys. Many (346/589; 58.7%) indicated that they were interested in receiving tailored, ongoing follow-up information from their HCP. Nearly half (n = 281; 47.7%) preferred an opt-in service and 293/589 (49.7%) an opt-out service for receiving follow-up information. Reasons for preferring an opt-in service were being in control of the information received (n = 254); able to make a decision that is best for them (n = 245); opt-in service would save time for HCPs (n = 217); they may not want or need the information (n = 240). Many (n = 255) felt that an opt-out service should be part of the normal duty of care of their HCP and believed (n = 267) that this approach would ensure that everyone has access to information.

CONCLUSIONS

Respondents were interested in receiving tailored information outside of consultation times. However, preferences for an opt-in or opt-out approach were divided.

Understanding the Meaning of Lived Experience "Maternal Near Miss": A Qualitative Study Protocol

Background: Maternal near-miss (MNM) is defined as "a woman who almost died but survived a serious maternal complication during pregnancy, childbirth, or within 42 days of completion of pregnancy". Despite the long-term physical and psychological burden of this event on the mother's life, the meaning of MNM is not clear. In addition, the mother's role complicates the understanding of this phenomenon. Therefore, this study aimed to understand lived experience of Iranian "near-miss" mothers in the postpartum period. Methods: In this Heideggerian phenomenological study, we used Souza and colleagues' theoretical framework to understand the meaning of the lived experience of near-miss mothers in-depth. The participants had experienced MNM at least one year ago by World Health Organization (WHO)approach in multicenter, academic, tertiary care hospitals in Mashhad, Iran. Taking into account reflexivity and after obtaining ethical approval, participants were purposively sampled using semi-structured interviews, and data analysis was conducted by Diekelmann and colleagues up to data saturation. Data collection and analysis has been argued by Lincoln and Guba. Discussion: Our findings resulted in updating the existing knowledge about the meaning of MNM and its implication. Given the different needs and challenges of near-miss mothers, it is necessary to design a supportive program of primary care for them. Policymakers and managers should consider the lived experience of these mothers when planning and taking decisions.

General practitioners' views and experiences in caring for patients after sepsis: a qualitative interview study

BACKGROUND

Patients surviving critical illnesses, such as sepsis, often suffer from long-term complications. After discharge from hospital, most patients are treated in primary care. Little is known how general practitioners (GPs) perform critical illness aftercare and how it can be improved. Within a randomised controlled trial, an outreach training programme has been developed and applied.

OBJECTIVES

The aim of this study is to describe GPs' views and experiences of caring for postsepsis patients and of participating a specific outreach training.

DESIGN

Semistructured qualitative interviews.

SETTING

14 primary care practices in the metropolitan area of Berlin, Germany.

PARTICIPANTS

14 GPs who had participated in a structured sepsis aftercare programme in primary care.

RESULTS

Themes identified in sepsis aftercare were: continuity of care and good relationship with patients, GP's experiences during their patient's critical illness and impact of persisting symptoms. An outreach education as part of the intervention was considered by the GPs to be acceptable, helpful to improve knowledge of the management of postintensive care complications and useful for sepsis aftercare in daily practice.

CONCLUSIONS

GPs provide continuity of care to patients surviving sepsis. Better communication at the intensive care unit-GP interface and training in management of long-term complications of sepsis may be helpful to improve sepsis aftercare.

TRIAL REGISTRATION NUMBER

ISRCTN61744782.

Improving Rehabilitation Information-Giving to Intensive Care Unit Survivors to Aid in Physical and Psychological Recovery

Intensive care unit (ICU) survivors have an increased mortality rate and reduced quality of life associated with post-ICU syndrome: a triad of physical, psychiatric and cognitive decline. Following evidence on the benefits of early rehabilitation, the National Institute of Clinical Excellence (NICE) CG83 guidelines instruct the provision of rehabilitation information to ICU patients before discharge. Only 33% of UK trusts meet these guidelines. The aim of this project was to reach 100% patient and ICU therapist satisfaction with the rehabilitation information given before ICU discharge at Medway Maritime Hospital, within four months. Patient and therapist satisfaction was assessed using questionnaires at baseline and following each Plan-Do-Study-Act (PDSA) cycle. In PDSA1, a generalised rehabilitation information booklet was created and distributed to ICU survivors pre-discharge. For PDSA2, a personalised rehabilitation plan completed by therapists was added. During PDSA3, the booklet was enriched with mental health and speech and language therapy sections. Results showed a shift in patient satisfaction scores, indicating a significant change in the median from 20% at baseline to 87% after PDSA3. This was also reflected in the therapist satisfaction scores, which increased significantly from 60% at baseline to 100%. The introduction of a generalised information booklet, supplemented with a personalised recovery plan, is an effective way of increasing critical care patient and therapist satisfaction with post-discharge rehabilitation information provision. This should translate to greater patient engagement with rehabilitation and improved long-term outcomes. This is ever more pertinent, as the COVID-19 pandemic will exponentially increase the numbers of ICU survivors at risk of long-term morbidity and mortality.

What Matters to Patients and Their Families During and After Critical Illness: A Qualitative Study

BACKGROUND

Despite increased emphasis on providing higher-quality patient- and family-centered care in the intensive care unit (ICU), there are no widely accepted definitions of such care in the ICU.

OBJECTIVES

To determine (1) aspects of care that patients and families valued during their ICU encounter, (2) outcomes that patients and families prioritized after hospital discharge, and (3) outcomes perceived as equivalent to or worse than death.

METHODS

Semistructured interviews (n = 49) of former patients of an urban, academic medical ICU and their family members. Two investigators reviewed all transcripts line by line to identify key concepts. Codes were created and defined in a codebook with decision rules for their application and were analyzed using qualitative content analysis.

RESULTS

Salient themes were identified and grouped into 2 major categories: (1) processes of care within the ICU- communication, patient comfort, and a sense that the medical team was "doing everything" (ie, providing exhaustive medical care) and (2) patient and surrogate outcomes after the ICU-survival, quality of life, physical function, and cognitive function. Several outcomes were deemed worse than death: severe cognitive/physical disability, dependence on medical machinery/equipment, and severe/constant pain.

CONCLUSION

Although survival was important, most participants qualified this preference. Simple measures of mortality rates may not represent patient- or family-centered outcomes in evaluations of ICU-based interventions, and new measures that incorporate functional outcomes and patients' and family members' views of life quality are necessary to promote patient-centered, evidence-based care.

Patients' experiences of recovery: Beyond the intensive care unit and into the community

AIMS

To understand barriers and facilitators of recovery for critical illness survivors', who are discharged home from the hospital and do not have access to dedicated outpatient care.

DESIGN

Multi-site descriptive study guided by interpretive phenomenology using semi-structured interviews.

METHODS

Interviews were conducted between December 2017 -July 2018. Eighteen participants were included. Data were collected from interview recordings, transcripts, field notes, and a retrospective chart review for sample demographics. Analysis was completed using Interpretive Phenomenological Analysis which provided a unique view of recovery through the survivors' personal experiences and perception of those experiences.

RESULTS

Participants encountered several barriers to their recovery; however, they were resilient and initiated ways to overcome these barriers and assist with their recovery. Facilitators of recovery experienced by survivors included seeking support from family and friends, lifestyle adaptations, and creative management of their multiple medical needs. Barriers included unmet needs experienced by survivors such as mental health issues, coordination of care, and spiritual needs. These unmet needs left participants feeling unsupported from healthcare providers during their recovery.

CONCLUSION

This study highlights important barriers and facilitators experienced by critical illness survivors during recovery that need be addressed by healthcare providers. New ways to support critical illness survivors, that can reach a broader population, must be developed and evaluated to support survivors during their recovery in the community.

IMPACT

This study addressed ICU survivors' barriers and facilitators to recovery. Participants encountered several barriers to recovery at home, such as physical, cognitive, psychosocial, financial, and transportation barriers, however, these survivors were also resilient and resourceful in the development of strategies to try to manage their recovery at home. These results will help healthcare providers develop interventions to better support ICU survivors in the community.

Association between delirium in the intensive care unit and subsequent neuropsychiatric disorders

Background

Patients in the intensive care unit (ICU) are known to be at increased risk of developing delirium, but the risk of subsequent neuropsychiatric disorders is unclear. We therefore sought to examine the association between the presence of delirium in the ICU and incident neuropsychiatric disorders (including depressive, anxiety, trauma-and-stressor-related, and neurocognitive disorders) post-ICU stay among adult medical-surgical ICU patients.

Methods

Retrospective cohort study utilizing clinical and administrative data from both inpatient and outpatient healthcare visits to identify the ICU cohort and diagnostic information 5 years prior to and 1 year post-ICU stay. Patients ≥ 18 years of age admitted to one of 14 medical-surgical ICUs across Alberta, Canada, January 1, 2014–June 30, 2016, and survived to hospital discharge were included. The main outcome of interest was a new diagnosis of any neuropsychiatric disorder 1 year post-ICU stay. The exposure variable was delirium during the ICU stay identified through any positive delirium screen by the Intensive Care Unit Delirium Screening Checklist (ICDSC) during the ICU stay.

Results

Of 16,005 unique patients with at least one ICU admission, 4033 patients were included in the study of which 1792 (44%) experienced delirium during their ICU stay. The overall cumulative incidence of any neuropsychiatric disorder during the subsequent year was 19.7% for ICU patients. After adjusting for hospital characteristics using log-binomial regression, patients with delirium during the ICU stay had a risk ratio (RR) of 1.14 (95% confidence interval [CI] 0.98–1.33) of developing any neuropsychiatric disorder within 1 year post-ICU compared to those who did not experience delirium. Delirium was significantly associated with neurocognitive disorders (RR 1.59, 95% CI 1.08–2.35), but not depressive disorders (RR 1.16, 95% CI 0.92–1.45), anxiety (RR 1.16, 95% CI 0.92–1.47), and trauma-and-stressor-related (RR 0.82, 95% CI 0.53–1.28) disorders.

Conclusions

The diagnosis of new onset of neurocognitive disorders is associated with ICU-acquired delirium. In this study, significant associations were not observed for depressive, anxiety, and trauma-and-stressor-related disorders.

Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness: The Thrive Collaboratives

OBJECTIVES

Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them.

DESIGN

Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data.

SETTING

Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents.

SUBJECTS

Clinicians from 21 sites.

MEASUREMENT AND MAIN RESULTS

Ten enablers and nine barriers to implementation of "ICU follow-up clinics" were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of "peer support groups" were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising.

CONCLUSIONS

Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.

Stimulated by insight: Exploration of critical care nurses' experience of research participation in a recovery programme for intensive care survivors

AIMS AND OBJECTIVES

To explore critical care nurses' experiences of research participation during a one-year recovery programme for intensive care survivors.

BACKGROUND

Nurse-led postintensive care follow-up consultations have emerged to help patients to recover and overcome problems related to critical illness and admission at the intensive care unit (ICU). Previous research exploring post-ICU follow-up programmes have shown inconclusive evidence of their effectiveness on patient-reported outcome measurements, and provider evaluation is scarce. The context of this study is the Recovery and Aftercare in Postintensive care Therapy (RAPIT) trial.

DESIGN

A qualitative descriptive telephone interview study.

METHODS

Data were collected after completion of the RAPIT trial. Participants (n = 14) were trained intensive care nurses, who delivered the post-ICU recovery programme, representing nine out of ten sites from the RAPIT trial. Two focus group discussions were used to construct a semistructured interview guide. A thematic data analysis was performed using Braun and Clark's six-step method. This study conforms to the COREQ Research Reporting Guidelines for qualitative studies.

RESULTS

Our study indicated that nurses considered participation in research as a positive experience. The main finding "Stimulated by insight" described how nurses' engagement and professional growth was gained by reflection, patient feedback and research competencies acquired in the clinical setting. The research programmes stimulated to new knowledge, broaden their perspectives and enhanced critical reflection of ICU nursing practice.

CONCLUSIONS

The study indicates that nurses developed research competencies and enhanced their job satisfaction by using critical reflection and patient feedback. However, there is still a substantial need for support to strengthen nurses' competencies in collaboration with colleagues, managers and researchers.

RELEVANCE TO CLINICAL PRACTICE

This study can contribute to the development of recommendations supporting nurses doing research and to optimise implementation of clinical research.

Implementation of an ICU Recovery Clinic at a Tertiary Care Academic Center

Post-ICU clinics may facilitate the care of survivors of critical illness, but there is a paucity of data describing post-ICU clinic implementation. We sought to describe implementation of our ICU recovery clinic, including an assessment of barriers and facilitators to clinic attendance.

DESIGN

Adults admitted to the medical ICU of a large tertiary care academic hospital with shock and/or respiratory failure requiring mechanical ventilation were screened for participation in a newly formed ICU recovery clinic. Participant selection and attendance rates were tracked. Reasons for nonattendance were assessed by phone call in a subset of patients.

SETTING

A newly formed ICU recovery clinic of a large tertiary care academic hospital.

PATIENTS

All patients admitted to the medical ICU were screened.

INTERVENTIONS

ICU recovery clinic appointments were scheduled for all eligible patients. A subset of nonattenders were called to assess reasons for nonattendance.

MEASUREMENTS AND MAIN RESULTS

Over 2 years, we admitted 5,510 patients to our medical ICU. Three hundred sixty-two were screened into the recovery clinic. One-hundred sixty-six were not scheduled for clinic; major reasons included discharge to hospice/death in the hospital (n = 55) and discharge to a facility (n = 50). One-hundred ninety-six patients were scheduled for a visit and of those, 101 (52%) arrived to clinic. Reasons for nonattendance in a surveyed subset of nonattenders included patient's lack of awareness of the appointment (50%, n = 9/18), financial concerns (17%, n = 3/18), and transportation difficulty (17%, n = 3/18).

CONCLUSIONS

ICU recovery clinics may address the needs of survivors of critical illness. Barriers to clinic attendance include high mortality rates, high rates of clinic appointment cancelations and nonattendance, and discharge to locations such as skilled nursing facilities or long-term acute care hospitals. Improved communication to patients about the role of the clinic may facilitate attendance and minimize canceled appointments.

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.

Intervention fidelity in postintensive care follow-up consultations at ten sites in the RAPIT-trial: A mixed-methods evaluation

AIM

The aim of the study was to evaluate intervention fidelity of nurses' delivery of the RAPIT recovery program for postintensive care patients.

BACKGROUND

Interventions addressing patient problems after intensive care lack description of the process of delivery and the evidence of their effectiveness. This is needed to understand how these interventions work.

DESIGN

Multistage intervention framework in a mixed-methods design. Intervention fidelity strategies were assessed for intervention design, training, delivery, receipt, and enactment with quantitative and qualitative methods inspired by the Medical Research Council and the National Institutes of Health Fidelity Framework.

METHODS

Data collection was embedded in a multicenter randomized controlled trial to explore intervention fidelity of a recovery program (December 2012-February 2017). Ten Danish intensive care units participated in the RAPIT-trial including 386 patients and 27 nurses. Quantitative data covered training and delivery. Qualitative data explored design, quality of delivery, receipt, and enactment seen from nurses' and patients' perspectives. Data were analysed statistically and by systematic deductive-inductive thematic analysis.

FINDINGS

A framework for participatory enactment of a complex intervention was developed and demonstrated delivery with high consistent fidelity across sites. Low delivery doses and variations were related to the program, patient, provider nurses and context.

CONCLUSION

Our study provides insight into the process of intervention fidelity of a nurse-led postintensive care recovery program and potentially enables professionals to understand key factors in cross-site implementation. Although we demonstrate consistent delivery and variations suggest that some patients may benefit more than others.

Improving Quality of Life in Patients at Risk for Post-Intensive Care Syndrome

Objective

To improve quality of life (QOL) in patients at risk for post-intensive care syndrome (PICS).

Patients and Methods

We conducted a mixed-method, prospective, observational, pre-post interventional study in an adult medical and mixed medical/surgical/transplant intensive care unit (ICU) at a tertiary academic hospital. Preintervention included patients admitted from October 1 through October 31, 2016, and postintervention included patients admitted from January 15 through February 14, 2017. First, a multidisciplinary team of stakeholders identified barriers associated with decreased QOL in patients at risk for PICS. Next, interventions were designed and implemented. The effect of interventions was assessed using a mixed-method analysis. The qualitative analysis used a modified grounded theory approach. The quantitative analysis included assessment of preexisting symptoms and risk factors associated with PICS. The 36-Item Short-Form Health Status Survey (SF-36), which surveys physical and mental composite scores, was used to assess QOL.

Results

Barriers identified were lack of awareness and understanding of PICS. Interventions included educational videos, paper and online education and treatment materials, and online and in-person support groups for education and treatment. After interventions, the qualitative analysis found that patients who participated in the interventions after hospital discharge showed improved QOL, whereas education during hospitalization alone was not effective. The quantitative analysis did not find improvement in QOL, as defined by SF-36 physical or mental composite scores.

Conclusion

Interventions targeted to patients after hospitalization may offer subjective improvement in QOL for those at risk for PICS.

The impact of follow-up visits and diaries on patient outcome after discharge from intensive care: A descriptive and explorative study

OBJECTIVES

To explore the possible effects of intensive care follow-up visits and diaries on patients physical and psychosocial problems at 2, 6, and 12 months after unit discharge as well as the patient' experiences of follow-up visits and diaries.

METHODS

A descriptive and explorative cohort design. Patients (n = 441) with a length of ICU stay for ≥24 hours, who responded to the 3-set 4P questionnaire were included. Patients were divided into groups depending on when they responded to the questionnaire and if had or had not a follow-up visit or a diary.

RESULTS

Patients found the follow-up visit and the diary valuable and helpful during the recovery. In the univariate general linear model analyses, the follow-up group reported more problems in Mood and Memory. Longer length of stay was a predictor for unfavourable scoring in the domains Change in Appearance and Memory and for favourable scoring in the domain Social Life. The diary group reported more problems in Change in Appearance, Mood, and Memory and fewer problems in Social Life.

CONCLUSION

No strong effects of follow-up or diary on patient outcomes were seen. However, because the patients experienced that the interventions had helped them during recovery, further exploration of the matter is needed in the process of testing these interventions.

Physical function impairment in survivors of critical illness in an ICU Recovery Clinic

PURPOSE

The aims were to 1) determine feasibility of measuring physical function in our ICU Recovery Clinic (RC), 2) determine if physical function was associated with 6-month re-hospitalization and 1-year mortality and 3) compare ICU survivors' physical function to other comorbid populations.

MATERIALS AND METHODS

We established the Wake Forest ICU RC. Patients were seen in clinic 1month following hospital discharge. Testing included the Short Form-36 questionnaire and Short Physical Performance Battery (SPPB). We related these measures to 6month re-hospitalizations and 1year mortality, and compared patients' functional performance with other comorbid populations.

RESULTS

Thirty-six patients were seen in clinic from July 2014 to June 2015; the median SPPB score was 5 (IQR 5). The median SF-36 physical component summary score was 21.8 (IQR 28.8). Mortality was 14% at 1year. Of those who did not die by 1year, 35% were readmitted to our hospital within 6months of hospital discharge. SPPB scores demonstrated a non-significant trend with both mortality (p=0.06) and readmissions (p=0.09). ICU survivors' SPPB scores were significantly lower than those of other chronically ill populations (p<0.001).

CONCLUSIONS

Physical function measurement in a recovery clinic is feasible and may inform subsequent morbidity and mortality.

Intensive care survivors’ experiences of recovery after hospital discharge: A qualitative interview study

To suffer from a critical illness or injury requiring treatment in an Intensive Care Unit (ICU) is a traumatic experience that may affect patients and their relatives for a long time. This study aimed to explore intensive care survivors’ experiences of recovery after hospital discharge, from the patient perspective. A qualitative interview study with 12 interviews was conducted and analyzed using inductive content analysis. Four categories emerged from the data: Bodily changes, Emotional experiences, A prolonged struggle and Gratitude. The findings indicate that the life situation of intensive care survivors is changed, that recovery takes time and that the feeling of gratitude for having survived is strong.

Meeting the needs of critical care patients after discharge home: a qualitative exploratory study of patient perspectives

BACKGROUND

With improved survival rates in critical care, increasing focus is being placed on survivorship and how best to support patients in returning to their former activity. Little is known about what support patients themselves view as important, and this has implications for the efficacy and acceptability of services provided.

OBJECTIVES

To describe former critical care patients' perspectives on the support needed to optimize recovery.

STUDY DESIGN

This is a qualitative exploratory study of the experiences of support received by critical care survivors.

RESEARCH METHODOLOGY

Semi-structured interviews were undertaken with 12 critical care survivors recruited from a charity and a patient and public involvement group. The interviews were analysed using thematic analysis to describe patterns in the participants' experiences.

FINDINGS

Four themes of support were described: effective management of transfer anxiety, tailored information provision, timely access to services and a supportive social network.

CONCLUSION

Survivors of critical care should be equipped with information about their critical care stay, ongoing health issues and recovery and should be provided with holistic care at home. Critical care follow up was an effective way of meeting many of these needs, but this needs to be flexible to be useful to attendees. Peer support groups (face-to-face and online) provided information, reassurance, a social network and an avenue for those who had longer-lasting problems than current services provide for.

RELEVANCE TO CLINICAL PRACTICE

Whilst there are commonalities in the problems faced by critical care survivors, recovery is highly individualized, and current support services do not have sufficient flexibility to cater for this. This study shows that many survivors experience after-effects of critical care that outlast the support they are given. These longer-term survivors are often excluded from research studies because of fears of recall bias, resulting in poor understanding of their experiences.

Critical Care Follow-up Clinics: A Scoping Review of Interventions and Outcomes

OBJECTIVE

The purpose of this scoping review is to identify evidence describing benefits of interventions provided in intensive care unit (ICU) survivor follow-up clinics.

BACKGROUND

Advances in ICU treatments have increased the number of survivors who require specialized care for ICU-related sequelae. Intensive care unit survivor follow-up clinics exist, yet little is known about the nature and impact of interventions provided in such clinics. A scoping review of publications about in-person post-ICU follow-up care was undertaken.

METHOD

Ten databases were searched yielding 111 relevant unique publication titles and abstracts. Sample heterogeneity supported using a scoping review method. After excluding nonrelated publications, 33 reports were fully reviewed. Twenty international publications were included that described ICU follow-up clinic interventions and/or outcomes.

RESULTS

Authors discussed very diverse interventions in 15 publications, and 9 reported some level of intervention effectiveness. Evidence was strongest that supported the use of prospective diaries as an intervention to prevent or improve psychological symptoms, whereas evidence to support implementation of other interventions was weak.

CONCLUSIONS

Although ICU follow-up clinics exist, evidence for interventions and effectiveness of treatments in these clinics remains underexplored.

IMPLICATIONS

Intensive care unit survivor follow-up clinics provide a venue for further interdisciplinary intervention research that could lead to better health outcomes for ICU survivors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIMS AND OBJECTIVES

To describe the patient experience of ICU recovery from a longitudinal perspective by analysing follow-up consultations at three time-points.

BACKGROUND

After a stay in the intensive care unit, patients risk physical and psychological problems during recovery. Follow-up after intensive care has emerged to aid psychological recovery, and improve health-related quality of life. More insight is needed into the mechanisms of intensive care recovery.

DESIGN

A descriptive multicenter longitudinal qualitative design.

METHODS

A subsample of 36 consultations with 12 patients strategically selected from a randomised controlled trial on intensive care recovery from 10 Danish intensive care units. Data were generated during an ICU recovery programme including three consultations (at 1-3, 4-5, 9-11 months). First consultation was face-to-face using patient photographs to aid memory. Second and third consultations were by telephone using reflection sheets to focus dialogue. Thematic analysis and narrative theory were used to explore mechanisms of recovery using audio-recordings of consultations, patient photographs and reflection sheets as the sources of data.

RESULTS

The basic narrative of recovery was 'toward a trajectory of new orientation'. This narrative contained the chronological narratives of being 'at death's door', 'still not out of the woods' and 'on the road to recovery'. The road to recovery was described as downhill, steady-state or progressive. New orientation was obtained in steady-state or progressive recovery.

CONCLUSIONS

This study provides a contemporary understanding of the process of intensive care recovery. Recovery evolves through narratives of mortal danger, risk of relapse and moving forward towards a new orientation in life.

RELEVANCE TO CLINICAL PRACTICE

These findings enable health care professionals to understand what patients experience during stages of recovery. This is important to improve health care professionals in the assessment of long-term outcome, and management of patients after intensive care.

"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.