To describe the symptom experiences of family members of patients at high risk for dying in the intensive care unit and to assess risk factors associated with higher symptom burden.
Prospective, ...cross-sectional study.
Three intensive care units at a large academic medical center.
A sample of 74 family members of 74 intensive care unit patients who had a grave prognosis and were judged to be at high risk for dying. Patients at high risk for dying were identified as having Acute Physiology and Chronic Health Evaluation II scores >20, an intensive care unit length of stay >72 hrs, and being mechanically ventilated.
None.
We assessed the degree of symptom burden approximately 4 days after the patient's admission to the intensive care unit in the following domains: traumatic stress, anxiety, and depression. Overall, the prevalence of symptoms was high, with more than half (57%) of family members having moderate to severe levels of traumatic stress, 80% having borderline symptoms of anxiety, and 70% having borderline symptoms of depression. More than 80% of family members had other physical and emotional symptoms, such as fatigue, sadness, and fear, and these were experienced at the moderate to severe levels of distress. Factors independently associated with greater severity of symptoms included younger age, female gender, and non-white race of the family member. The only patient factor significantly associated with symptom severity was younger age. Despite their symptom experience, the majority of the family members were coping at moderate to high levels and functioning at high levels during the intensive care unit experience.
We document a high prevalence of psychological and physical symptoms among family members during an intensive care unit admission. These data complement existing data on long-term symptom burden and highlight the need to improve family centered care in intensive care units.
Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle ...performance and patient-centered outcomes in critical care.
Prospective, multicenter, cohort study from a national quality improvement collaborative.
68 academic, community, and federal ICUs collected data during a 20-month period.
15,226 adults with at least one ICU day.
We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.
Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio AOR, 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).
ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.
To provide a focused, detailed assessment of the symptom experiences of intensive care unit patients at high risk of dying and to evaluate the relationship between delirium and patients' symptom ...reports.
Prospective, observational study of patients' symptoms.
Two intensive care units in a tertiary medical center in the western United States.
One hundred seventy-one intensive care unit patients at high risk of dying.
None.
Patients were interviewed every other day for up to 14 days. Patients rated the presence, intensity (1 = mild; 2 = moderate; 3 = severe), and distress (1 = not very distressing; 2 = moderately distressing; 3 = very distressing) of ten symptoms (that is, pain, tired, short of breath, restless, anxious, sad, hungry, scared, thirsty, confused). The Confusion Assessment Method-Intensive Care Unit was used to ascertain the presence of delirium. A total of 405 symptom assessments were completed by 171 patients. Patients' average age was 58 ± 15 yrs; 64% were males. Patients were mechanically ventilated during 34% of the 405 assessments, and 22% died in the hospital. Symptom prevalence ranged from 75% (tired) to 27% (confused). Thirst was moderately intense, and shortness of breath, scared, confusion, and pain were moderately distressful. Delirium was found in 34.2% of the 152 patients who could be evaluated. Delirious patients were more acutely ill and received significantly higher doses of opioids. Delirious patients were significantly more likely to report feeling confused (43% vs. 22%, p = .004) and sad (46% vs. 31%, p = .04) and less likely to report being tired (57% vs. 77%, p = .006) than nondelirious patients.
Study findings suggest that unrelieved and distressing symptoms are present for the majority of intensive care unit patients, including those with delirium. Symptom assessment in high-risk intensive care unit patients may lead to more focused interventions to avoid or minimize unnecessary suffering.
Predictors of Thirst in Intensive Care Unit Patients Stotts, Nancy A., RN, EdD; Arai, Shoshana R., PhD, RN; Cooper, Bruce A., PhD ...
Journal of pain and symptom management,
03/2015, Letnik:
49, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Abstract Context Thirst is a pervasive, intense, and distressing symptom in intensive care unit (ICU) patients. Although thirst may be avoided and/or treated, scant data are available to help ...providers identify patients most in need. Objectives This study was designed to identify predictors of the presence, intensity, and distress of thirst in ICU patients. Methods This descriptive cross-sectional study enrolled 353 patients from three ICUs (medical-surgical, cardiac, and neurological). To measure outcomes, patients were asked to report the presence of thirst (yes/no) and, if present, to rate its intensity and distress on zero to 10 numeric rating scales (10 = worst). Predictor variables were demographic (e.g., age), treatment-related (e.g., opioids), and biological (e.g., total body water). Data were analyzed with logistic regression and truncated regression with alpha preset at 0.05. Results Thirst presence was predicted by high opioid doses (≥50 mg), high furosemide doses (>60 mg), selective serotonin reuptake inhibitors, and low ionized calcium. Thirst intensity was predicted by patients not receiving oral fluid and having a gastrointestinal (GI) diagnosis. Thirst distress was predicted by mechanical ventilation, negative fluid balance, antihypertensive medications, and a GI or “other” diagnosis. Conclusion Thirst presence was predicted by selected medications (e.g., opioids). Thirst intensity and/or thirst distress were predicted by other treatments (e.g., mechanical ventilation) and medical diagnoses (e.g., GI). This is one of the first studies describing predictors of the multidimensional characteristics of thirst. Clinicians can use these data to target ICU patients whose thirst might warrant treatment.
Family members of patients in intensive care are at increased risk for psychological symptoms.
To compare levels of posttraumatic stress disorder, anxiety, and depression during and 3 months after ...the intensive care experience in family members of patients at high risk for dying and to determine if differences were related to the patient's final disposition.
Longitudinal descriptive study of 41 family members in 3 tertiary care intensive care units.
By repeated-measures analysis of variance, family members' levels of posttraumatic stress disorder were significantly lower (P = .01) at 3 months after (mean score, 1.27; SD, 0.86) than during (mean, 1.61; SD, 0.81) the experience. Mean anxiety and depression scores were significantly lower (P < .001) after (anxiety: 7.35; SD, 3.91; depression: 5.63; SD, 4.58) than during (anxiety: 11.5; SD, 4.88; depression: 9.51; SD, 4.31) the experience. Scores for posttraumatic stress disorder, anxiety, and depression did not differ significantly between family members of patients who died and family members of patients who survived. Yet, all 13 family members of deceased patients and 42% of the total sample of 41 had traumatic stress scores of 1.5 or greater. Among the total sample, 44% had significant anxiety, and 27% were depressed.
Family members' symptoms of posttraumatic stress disorder, anxiety, and depression significantly decreased 3 months after the intensive care experience and did not differ according to the patients' final disposition. However, many family members still had significant risk for posttraumatic stress disorder and borderline anxiety and depression at 3 months.
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.
To assess patients' recollections of in-ICU procedural pain and its impact on post-ICU burden.
Prospective longitudinal study of patients who underwent ICU procedures.
Thirty-four ICUs in France and ...Belgium.
Two hundred thirty-six patients who had undergone ICU procedures.
None.
Patients were interviewed 3-16 months after hospitalization about: 1) recall of procedural pain intensity and pain distress (on 0-10 numeric rating scale); 2) current pain; that is, having pain in the past week that was not present before hospitalization; and 3) presence of traumatic stress (Impact of Events Scale). For patients who could rate recalled procedural pain intensity (n = 56) and pain distress (n = 43), both were significantly higher than their median (interquartile range) in ICU procedural pain scores (pain intensity: 5 4-7 vs 3 2.5-5, p < 0.001; pain distress: 5 2-6 vs 2 0-6, p = 0.003, respectively.) Current pain was reported in 14% of patients. When comparing patients with and without current pain, patients with current pain recalled even greater ICU procedural pain intensity and pain distress scores than patients without current pain: pain intensity, 8 (6-8) versus 5 (3.25-7); p = 0.002 and pain distress, 7 (5-8) versus 4 (2-6); p = 0.01, respectively. Patients with current pain also had significantly higher Impact of Events Scale scores than those without current pain (8.5 3.5-24 vs 2 0-10; p < 0.001).
Many patients remembered ICU, with far fewer able to rate procedure-associated pain. For those able to do so, recalled pain intensity and pain distress scores were significantly greater than reported in ICU. One in seven patients was having current pain, recalling even higher ICU procedural pain scores and greater traumatic stress when compared with patients without current pain. Studies are needed to assess the impact of ICU procedural pain on post-ICU pain recall, pain status over time, and the relationship between postdischarge pain status and post-ICU burden.
Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical ...interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.
To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings.
We searched the MEDLINE database from inception to April 2010 for all ...English language articles using the terms "intensive care," "critical care," or "ICU" and "palliative care"; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report.
We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families.
There are two main models for intensive care unit-palliative care integration: 1) the "consultative model," which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the "integrative model," which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit-palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit-palliative care initiative can provide important benefits for patients, families, and providers.
PDF
