The Experience of a Neurocritical Care Admission and Discharge for Patients and Their Families: A Qualitative Analysis

INTRODUCTION

A qualitative assessment of discharge resource needs is important for developing evidence-based care improvements in neurocritically ill patients.

METHODS

We conducted a quality improvement initiative at an academic hospital and included all patients admitted to the neuroscience intensive care unit (ICU) during an 18-month period. Telephone assessments were made at 3 to 6 months after admission. Patients or caregivers were asked whether they had adequate resources upon discharge and whether they had any unanswered questions. The content of responses was reviewed by a neurointensivist and a neurocritical care nurse practitioner. A structured codebook was developed, organized into themes, and applied to the responses.

RESULTS

Sixty-one patients or caregivers responded regarding access to resources at discharge with 114 individual codable responses. Responses centered around 5 themes with 23 unique codes: satisfied, needs improvement, dissatisfied, poor post-ICU care, and poor health. The most frequently coded responses were that caregivers believed their loved one had experienced an unclear discharge (n = 11) or premature discharge (n = 12). Two hundred four patients or caregivers responded regarding unanswered questions or additional comments at follow-up, with 516 codable responses. These centered around 6 themes with 26 unique codes: positive experience, negative experience, neutral experience, medical questions, ongoing medical care or concern, or remembrance of time spent in the ICU. The most frequent response was that caregivers or patients stated that they received good care (n = 115). Multiple concerns were brought up, including lack of follow-up after hospitalization (n = 15) and dissatisfaction with post-ICU care (n = 15).

CONCLUSIONS

Obtaining qualitative responses after discharge provided insight into the transition from critical care. This could form the basis for an intervention to provide a smoother transition from the ICU to the outpatient setting.

Combining role-play with interactive simulation to motivate informed climate action: Evidence from the World Climate simulation

Climate change communication efforts grounded in the information deficit model have largely failed to close the gap between scientific and public understanding of the risks posed by climate change. In response, simulations have been proposed to enable people to learn for themselves about this complex and politically charged topic. Here we assess the impact of a widely-used simulation, World Climate, which combines a socially and emotionally engaging role-play with interactive exploration of climate change science through the C-ROADS climate simulation model. Participants take on the roles of delegates to the UN climate negotiations and are challenged to create an agreement that meets international climate goals. Their decisions are entered into C-ROADS, which provides immediate feedback about expected global climate impacts, enabling them to learn about climate change while experiencing the social dynamics of negotiations. We assess the impact of World Climate by analyzing pre- and post-survey results from >2,000 participants in 39 sessions in eight nations. We find statistically significant gains in three areas: (i) knowledge of climate change causes, dynamics and impacts; (ii) affective engagement including greater feelings of urgency and hope; and (iii) a desire to learn and do more about climate change. Contrary to the deficit model, gains in urgency were associated with gains in participants’ desire to learn more and intent to act, while gains in climate knowledge were not. Gains were just as strong among American participants who oppose government regulation of free markets–a political ideology that has been linked to climate change denial in the US–suggesting the simulation’s potential to reach across political divides. The results indicate that World Climate offers a climate change communication tool that enables people to learn and feel for themselves, which together have the potential to motivate action informed by science.

Lack of awareness in both patients and physicians contributes to a high rate of late presentation in a South West German HIV patient cohort

PURPOSE

To assess rate of late presentation with HIV in Southwestern Germany and to identify patient characteristics correlated with CD4 nadir.

METHODS

Patients with primary diagnosis who presented to one of ten participating clinics rated on knowledge and behavior towards HIV testing on a self-developed questionnaire, whereas clinical data was assessed by the physician.

RESULTS

161 patients were included. Risk factors were homosexual (59.5 %) or heterosexual contacts (26.8 %), drug use (2.0 %), migration (3.9 %), or others (7.8 %). 63.5 % had a CD4 T cell count < 350/µl. 52.5, 17.4, and 31.1 % were diagnosed in CDC stadium A, B or C, respectively. 209 disease episodes were reported, from whom 83.7 % had led to the diagnosis of HIV. 75.2 and 68.3 % said to have been well-informed about ways of transmission and testing offerings, respectively, and 20.4 % admitted to have psychologically repressed the possibility of being infected. 48 patients rated their personal behavioral risk as "high" or "very high". Of these, however, only ten had performed at test in the precedent year. Performing a regression analysis, younger age and previous testing were correlated with a higher CD4 T cell nadir (p = 0.005, and 0.018, resp.).

CONCLUSION

The rate of late presentation in this region was even higher compared to national or European surveys. Most infected patients perceived to have had only a low risk. Several disease episodes did not lead to the initiation of HIV testing by the physician.

Community's knowledge and perceptions about filarial elephantiasis and hydrocele in coastal Orissa, India

This study assesses people's knowledge and perceptions on transmission, prevention and eradication of elephantiasis and hydrocele, common manifestations of chronic lymphatic filariasis (LF). The assessment was done during mass drug administration (MDA) of the programme to eliminate LF in the State of Orissa, India. A household survey with pre-tested interview questionnaire was conducted in four LF endemic districts of Orissa state, India, where the MDA has been taken place. The sampling units (clusters of households) of the household survey are taken based on (1) urban/rural and (2) type of or absence of health facility. A total of 1,448 respondents were selected randomly. Majority of the respondents heard about elephantiasis and hydrocele. About one third of them know that mosquito bite is the cause of elephantiasis but very few people know about hydrocele. Around 50% of the respondent believed that elephantiasis could be cured completely, while almost 60% said that it could be totally removed from the community. But for hydrocele, more than 80% of respondents showed a positive approach for cure and nearly about 70% said that hydrocele could totally be eradicated from community. Various causes and methods of cure and prevention were suggested. Around 55% of respondents suggested that elephantiasis can be eradicated by taking medicine, but only 40% felt that hydrocele can be cured by taking medicine. Basic knowledge on LF is poor and relatively low proportion of people knows that LF can be eliminated by taking medicine. As there are plans to undertake further rounds of MDA in Orissa, people's knowledge has to be strengthened and perception and attitudes have to be addressed to achieve positive behavioural change, which eventually lead to higher compliance of MDA.

Use of an inclusive-partnership strategy in urban areas of Orissa, India, to increase compliance in a mass drug administration for the control of lymphatic filariasis

In India, the programme to eliminate lymphatic filariasis, which is largely based on mass administrations of diethylcarbamazine, has, in terms of coverage and compliance, been generally much less successful in urban areas than in rural communities. An innovative strategy to make the programme more effective in urban settings, largely based on an inclusive partnership and community participation, has recently been developed. An evaluation of the strategy's implementation in Orissa, which employed both quantitative and qualitative methods of data collection, revealed significantly higher coverage and compliance in an urban area where the strategy had been implemented than in a similar urban area where there had been no such intervention. Application of this strategy in other urban settings in general, and in small towns in particular, is recommended in India.

Knowledge and perceptions about lymphatic filariasis: a study during the programme to eliminate lymphatic filariasis in an urban community of Orissa, India

This study reports the knowledge and perceptions of the people with regard to cause and transmission of chronic forms of lymphatic filariasis (LF) and its elimination programme during mass drug administration (MDA) under the programme to eliminate LF in an urban area of Orissa, India. The paper is based on both quantitative and qualitative surveys undertaken before and after the first MDA among different socio-economic strata of the urban area. The data revealed that the urban residents are aware of the chronic forms of LF and also felt that LF is a problem in their area. But most of them do not know the role of mosquitoes in the transmission of the disease. A few people explained the association between LF and hydrocele, and the role of mosquitoes. In the present study, it is observed that poor knowledge about LF is highly influenced by socioeconomic conditions. People from lower economic category were least aware of the cause of both lymphoedema and hydrocele. However, knowledge in some issues with regards to the disease and the awareness on MDA have increased significantly after MDA.

Impact of chronic lymphatic filariasis on quantity and quality of productive work among weavers in an endemic village from India

OBJECTIVE

To assess the impact of hydrocele and lymphoedema on the quantity and quality of productive work of weavers.

METHOD

Case-control study in an endemic village in Andhra Pradesh, India. We collected qualitative data on work activities from cases and age- and sex-matched controls through informal discussions and observation.

RESULTS

The mean (+/-standard deviation) daily work time of cases was 7.38 h (+/-2.47), significantly less than that of controls (8.17+/-2.41 h). Lost work time was equivalent to around 29 days of work in a year. Gender had significant influence on the mean number of working hours in this occupational group. Most cases could not weave, which is physically demanding, and preferred less strenuous tasks such as spinning, starching, dyeing or sizing. Hard physical labour constitutes 71.5% of total work time among patients and 83.7% in controls. As income also depends on the type of work, cases earn less.

CONCLUSIONS

Filariasis has an adverse impact on the productivity of weavers, and morbidity management strategies and control programmes need to take this into account.

Adverse reactions following mass drug administration during the Programme to Eliminate Lymphatic Filariasis in Orissa State, India

The frequency and severity of adverse reactions are the main reasons for low compliance of mass drug administration (MDA) under the Programme to Eliminate Lymphatic Filariasis (PELF). This paper reports the frequency and types of adverse reactions during two MDAs during January 2002 and September 2004 in the State of Orissa, India. Of the people who consumed the drugs, 15.5% in the 2002 MDA and 16.5% in the 2004 MDA reported one or more adverse reactions. This rate is higher (49.7%) in a group of individuals who were monitored for 6 days from the day of consumption of drugs during the 2002 MDA. However, many of these reactions were mild. No significant difference was found in the frequency of adverse reactions between MDA with diethylcarbamazine (DEC) alone and with DEC and albendazole. Significant gender differences were found in the 2004 MDA but no such differences were found in the 2002 MDA; however, the frequency of adverse reactions increased with age. Of all the adverse reactions, systemic adverse reactions typically associated with microfilarial death were more frequent. The frequency of adverse reactions was higher in microfilaraemics compared with amicrofilaraemic controls. The present study warrants developing an active adverse reaction surveillance system to minimise the impact of adverse reactions on MDA compliance.

Use of the Dermatology Life Quality Index in filarial lymphoedema patients

The global programme to eliminate lymphatic filariasis has alleviation of suffering and disability as one of its components, and many efforts are being taken across the globe in this direction. However, there is no effective tool to assess the impact of these efforts on patients' quality of life and/or lessening of disability and suffering. The present paper reports the use of the Dermatology Life Quality Index (DLQI) in filarial lymphoedema patients. DLQI scores were collected from 203 patients recruited from a clinic and from the community. The DLQI score ranged from 0 to 17, and a mean score of 2.7 (SD 4.4) or 9.0% disability. This score is lower than many skin diseases reported so far. The scores for individual questions vary, but the degree of consistency of responses between questions is high. The differences between sexes, place of recruitment and grades of lymphoedema are not significant. Although the DLQI measures the quality of life due to lymphoedema, this study further warrants development of a good quality-of-life index for lymphoedema patients.

A randomized clinical trial to compare the efficacy of three treatment regimens along with footcare in the morbidity management of filarial lymphoedema

The progression of lymphoedema to elephantiasis associated with increased incidence of episodic adeno-lymphangitis (ADL) is of great concern, as it causes physical suffering, permanent disability and economic loss to lymphatic filariasis patients. This randomized clinical trial aimed to assess the efficacy in terms of reduction of oedema and ADL frequency of three treatment regimens among lymphoedema patients from Orissa, India. The regimens were: (I) oral penicillin--one tablet of 800 000 U penicillin G potassium twice daily for 12 days--repeated every 3 months for 1 year; (II) diethylcarbamazine--6 mg/kg bodyweight for 12 days-repeated every 3 months for 1 year; and (III) topical antiseptic, i.e. betadine ointment. Foot care was part of all regimens. All three drug regimens are efficacious in reducing oedema and frequency of ADL episodes. Although the efficacy was slightly higher in regimen I, the difference was not significant. About half of all patients had reduced oedema after the 90 days of treatment, with oedema reduction of 75-100% in 20%. A major proportion of the remaining patients had oedema reduced by less than 25%. The proportion of people whose oedema reduced was slightly but not significantly lower in regimen II. anova revealed that lymphoedema reduction varied according to grade; being greatest at grade 1 lymphoedema, followed by grade 2. All three regimens significantly reduced ADL frequency after 1 year of treatment. This may be because of foot care as well as use of antibiotics. The estimated costs of treatment per patient for a period of 3 months are US$2.4, 1.5 and 4.0 respectively for regimen I, II and III. Thus affordable treatments with simple antibiotics and foot care can give substantial relief to the patients and reverse early lymphoedema.

SHORT syndrome and insulin resistance

We describe a further case of SHORT syndrome. This girl shows nearly all the typical manifestations reported in patients with SHORT syndrome. However, at 14 years she presented with non-ketotic hyperglycemia. At 16 1/2 years, the diagnosis of diabetes mellitus secondary to severe insulin resistance was made by intravenous insulin challenge. Insulin resistant diabetes mellitus seems to be a new finding in SHORT syndrome, not previously described in this condition.

[Oxygen tension in skeletal muscle in patients with reduced O2-carrying capacity (author's transl)]

In 10 patients (age: 31--72 years) oxygen supply of skeletal muscle was measured by pO2-multiwire technique. All patients suffered from chronic renal failure of differing etiologies and from chronic renal anemia. In muscle tissue 1,128 different O2-tensions were registered and the results were expressed as pO2-histograms. Seven of these pO2-histograms show a normal distribution, three are shifted to the left to lower O2-tensions. Therefore the microcirculation in the skeletal muscle of patients with chronic reduced O2-carrying capacity is largely undisturbed. The microcirculation is able to increase with exercise as shown by a shift to the right in the PO2-histogram. The use of the pO2-multiwire electrode is largely devoid of risk to the patient. Important pathological features may be demonstrated.

[Plasma erythropoietin and hematocrit under the influence of chronic hemodialysis treatment (author's transl)]

Hematocrit and plasma ESF titers were determined at 2 to 3 weeks intervals in 21 patients with chronic renal failure prior to and during a 15-weeks' period following initiation of chronic intermittent hemodialysis. While hematocrits increased from 22 to 27%, plasma ESF titers were found unchanged between 31 and 35 mU/ml. It can be excluded therefore that the improvement of erythropoiesis following initiation of dialysis was in part due to an increase in plasma ESF titers. The increased erythropoiesis observed is probably not dependent on increased ESF production. A 30-fold ESF deficit existed in patients with renal failure prior to the initiation of hemodialysis when compared with 5 patients with aplastic anemia (hematocrit 23%, plasma ESF titer 1115 mU/ml). At one exception ESF titers up to 500 mU/ml were found in dialysed patients only in combination with anemia due to acute bleeding or iron deficiency. ESF production is appropiate to the degree of anemia in patients with proper renal function after kidney transplantation.