This Viewpoint emphasizes the importance of advanced care planning and goals-of-care discussions with older patients and those with chronic disease during the spread of coronavirus disease ...(COVID-19), given the likelihood these patients could become critically ill and require resuscitation and advanced life support if they became infected with SARS-CoV-2.
Lung cancer screening (LCS) can reduce lung cancer mortality; however, poor understanding of results may impact patient experience and follow-up. We sought to determine whether an informational ...handout accompanying LCS results can improve patient-reported outcomes and adherence to follow-up.
This was a prospective alternating intervention pilot trial of a handout to accompany LCS results delivery.
Patients undergoing LCS in a multisite program over a 6-month period received a mailing containing either: 1) a standardized form letter of LCS results (control) or 2) the LCS results letter and the handout (intervention).
A two-sided informational handout on commonly asked questions after LCS created through iterative mixed-methods evaluation with both LCS patients and providers.
The primary outcomes of 1)patient understanding of LCS results, 2)correct identification of next steps in screening, and 3)patient distress were measured through survey. Adherence to recommended follow-up after LCS was determined through chart review. Outcomes were compared between the intervention and control group using generalized estimating equations.
389 patients were eligible and enrolled with survey responses from 230 participants (59% response rate). We found no differences in understanding of results, identification of next steps in follow-up or distress but did find higher levels of knowledge and understanding on questions assessing individual components of LCS in the intervention group. Follow-up adherence was overall similar between the two arms, though was higher in the intervention group among those with positive findings (p = 0.007).
There were no differences in self-reported outcomes between the groups or overall follow-up adherence. Those receiving the intervention did report greater understanding and knowledge of key LCS components, and those with positive results had a higher rate of follow-up. This may represent a feasible component of a multi-level intervention to address knowledge and follow-up for LCS.
ClinicalTrials.gov NCT05265897.
The coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide.
How do regional differences and perceived lack of ICU resources ...affect critical care resource use and the well-being of HCPs?
Between April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout.
We included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction ARR, 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46).
Our findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.
OBJECTIVE:We conducted a systematic review to answer three questions1) Do advance care planning and palliative care interventions lead to a reduction in ICU admissions for adult patients with ...life-limiting illnesses? 2) Do these interventions reduce ICU length of stay? and 3) Is it possible to provide estimates of the magnitude of these effects?
DATA SOURCES:We searched MEDLINE, EMBASE, Cochrane Controlled Clinical Trials, and Cumulative Index to Nursing and Allied Health Literature databases from 1995 through March 2014.
STUDY SELECTION:We included studies that reported controlled trials (randomized and nonrandomized) assessing the impact of advance care planning and both primary and specialty palliative care interventions on ICU admissions and ICU length of stay for critically ill adult patients.
DATA EXTRACTION:Nine randomized controlled trials and 13 nonrandomized controlled trials were selected from 216 references.
DATA SYNTHESIS:Nineteen of these studies were used to provide estimates of the magnitude of effect of palliative care interventions and advance care planning on ICU admission and length of stay. Three studies reporting on ICU admissions suggest that advance care planning interventions reduce the relative risk of ICU admission for patients at high risk of death by 37% (SD, 23%). For trials evaluating palliative care interventions in the ICU setting, we found a 26% (SD, 23%) relative risk reduction in length of stay with these interventions.
CONCLUSIONS:Despite wide variation in study type and quality, patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay. Although SDs are wide and study quality varied, the magnitude of the effect is possible to estimate and provides a basis for modeling impact on healthcare costs.
OBJECTIVES:Family members of ICU survivors report long-term psychologic symptoms of posttraumatic stress disorder. We describe patient- and family-member risk factors for posttraumatic stress ...disorder symptoms among family members of survivors of acute respiratory distress syndrome.
DESIGN:Prospective cohort study of family members of acute respiratory distress syndrome survivors.
SETTING:Single tertiary care center in Seattle, Washington.
SUBJECTS:From 2010 to 2015, we assembled an inception cohort of adult acute respiratory distress syndrome survivors who identified family members involved in ICU and post-ICU care. One-hundred sixty-two family members enrolled in the study, corresponding to 120 patients.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:Family members were assessed for self-reported psychologic symptoms 6 months after patient discharge using the Posttraumatic Stress Disorder Checklist-Civilian Version, the Patient Health Questionnaire 9-item depression scale, and the Generalized Anxiety Disorder 7-item scale. The primary outcome was posttraumatic stress disorder symptoms, and secondary outcomes were symptoms of depression and anxiety. We used clustered multivariable logistic regression to identify patient- and family-member risk factors for psychologic symptoms. Posttraumatic stress disorder symptoms were present in 31% (95% CI, 24–39%) of family participants. Family member risk factors for posttraumatic stress disorder symptoms included preexisting mental health disorders (adjusted odds ratio, 3.22; 95% CI, 1.42–7.31), recent personal experience of serious physical illness (adjusted odds ratio, 3.07; 95% CI, 1.40–6.75), and female gender (adjusted odds ratio, 5.18; 95% CI, 1.74–15.4). Family members of previously healthy patients (Charlson index of zero) had higher frequency of posttraumatic stress disorder symptoms (adjusted odds ratio, 2.25; 95% CI, 1.06–4.77). Markers of patient illness severity were not associated with family posttraumatic stress disorder symptoms.
CONCLUSIONS:The prevalence of long-term posttraumatic stress disorder symptoms among family members of acute respiratory distress syndrome survivors is high. Family members with preexisting mental health disorders, recent experiences of serious physical illness, and family members of previously healthy patients are at increased risk for posttraumatic stress disorder symptoms.
Background: Patientsâ deaths in the ICU have been associated with a high burden of psychologic symptoms in families. This study identifies
characteristics associated with psychologic symptoms in ...family members.
Methods: Families of patients dying in the ICU or within 30 h of ICU discharge in 11 hospitals previously participated in a randomized
trial. In the current study, we assessed these families for symptoms of posttraumatic stress disorder (PTSD) and depression
with follow-up surveys. Outcomes included validated measures of PTSD (PTSD Checklist) and depressive (Patient Health Questionnaire)
symptoms. Predictors included family member mental-health history, involvement in decision making, and demographics.
Results: Surveys were completed by 226 families. Response rate was 46% in the original randomized trial and 82% in this study. Prevalence
(95% CI) of PTSD and depressive symptoms were 14.0% (9.7%-19.3%) and 18.4% (13.5%-24.1%), respectively. Family characteristics
associated with increased symptoms included: female gender (PTSD, P = .020; depression, P = .005), knowing the patient for a shorter duration (PTSD, P = .003; depression, P = .040), and discordance between family membersâ preferences for decision making and their actual decision-making roles (PTSD,
P = .005; depression, P = .049). Depressive symptoms were also associated with lower educational level ( P = .002). Families with psychologic symptoms were more likely to report that access to a counselor (PTSD, P < .001; depression, P = .003) and information about spiritual services might have been helpful while the patient was in the ICU (PTSD, P = .024; depression, P = .029).
Conclusions: Families demonstrated a high prevalence of psychologic symptoms after a death in the ICU. Characteristics associated with
symptoms may help target interventions to reduce these symptoms.
Trial registration: clinicaltrials.gov; Identifier: NCT00685893.
Assessing the impact of coronavirus disease 2019 (COVID-19) on intensive care unit (ICU) providers' perceptions of resource availability and evaluating the factors associated with emotional ...distress/burnout can inform interventions to promote provider well-being.
Between 23 April and 7 May 2020, we electronically administered a survey to physicians, nurses, respiratory therapists (RTs), and advanced practice providers (APPs) caring for COVID-19 patients in the United States. We conducted a multivariate regression to assess associations between concerns, a reported lack of resources, and 3 outcomes: a primary outcome of emotional distress/burnout and 2 secondary outcomes of (1) fear that the hospital is unable to keep providers safe; and (2) concern about transmitting COVID-19 to their families/communities.
We included 1651 respondents from all 50 states: 47% were nurses, 25% physicians, 17% RTs, and 11% APPs. Shortages of intensivists and ICU nurses were reported by 12% and 28% of providers, respectively. The largest supply restrictions reported were for powered air purifying respirators (56% reporting restricted availability). Provider concerns included worries about transmitting COVID-19 to their families/communities (66%), emotional distress/burnout (58%), and insufficient personal protective equipment (PPE; 40%). After adjustment, emotional distress/burnout was significantly associated with insufficient PPE access (adjusted relative risk aRR, 1.43; 95% confidence interval CI, 1.32-1.55), stigma from community (aRR, 1.32; 95% CI, 1.24-1.41), and poor communication with supervisors (aRR, 1.13; 95% CI, 1.06-1.21). Insufficient PPE access was the strongest predictor of feeling that the hospital is unable to keep providers safe and worries about transmitting infection to their families/communities.
Addressing insufficient PPE access, poor communication from supervisors, and community stigma may improve provider mental well-being during the COVID-19 pandemic.
To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU.
We used the Council of Medical Specialty Societies principles for the ...development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development.
The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice.
These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.
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