Postextubation dysphagia management in Danish intensive care units: A national survey.

BACKGROUND: Postextubation dysphagia (PED) is a common complication to endotracheal intubation in critically ill patients and may lead to pneumonia, prolonged ventilation, longer hospital stays, and increased mortality. Recognizing dysphagia is paramount to preventing adverse events. The aim of this study was to describe PED management by investigating practice in Danish intensive care units (ICUs) focusing on current practice in 2023 (screening, prevention, and treatment), perceived best practice (barriers and facilitators), and when possible, to compare practice in 2017 and 2023. METHODS: Self-reported, cross-sectional survey of dysphagia practice in Danish ICUs administered from April to May 2023. In addition, data were compared with the 2017 Dysphagia in Intensive Care Evaluation study, when possible. RESULTS: Only half of Danish ICUs reported to have a PED protocol, and less than half routinely screen patients for dysphagia after extubation. Most common screening methods were the oral mechanism examination, water test, and Facio-oral tract therapy. Nurses and physicians often relied on an overall physical assessment of the patient. Best treatment methods were uniformly agreed to be patient positioning, modification of food and fluids, use of ergonomic utensils, and compensatory maneuvers. Key barriers to dysphagia management were lack of specialized staff, under-recognition of dysphagia as a health issue, and lack of standardized protocols. CONCLUSION: Awareness of PED is increasing and identification, prevention, and treatment is slowly improving, but systematic implementation of protocols for dysphagia screening and treatment could enhance dysphagia management in Danish ICUs.

Delirium screening instruments.

Delirium in patients has well-documented adverse physical and mental outcomes. Delirium impairs patients' capacity to grasp and retain information, thus affecting their right to informed consent and active participation in treatment and care decisions. In Danish hospitals, delirium afflicts up to 50% of the elderly patients, yet it often goes unreported due to the absence of systematic screening. The selection of a screening tool should be contextually relevant. This review gives an overview of delirium screening instruments available in Danish, each with distinct advantages and disadvantages.

How flash mobs can be used for data collection in healthcare? A scoping review protocol.

BACKGROUND: Traditional research methods often involve a lengthy process, but the emergence of flash mobs as an innovative data collection method offers the potential to gather substantial data within a short time frame. Flash mobs draw inspiration from the concept of large groups organizing through the internet or mobile devices to perform a prearranged action in public. In healthcare research, flash mobs serve as research organizing method to investigate clinically relevant questions on a large scale within a limited period. AIMS: This study aims to present a study protocol for a scoping review that comprehensively maps the existing literature on the use of flash mobs as a data collection method in healthcare research. METHODS: The review will follow established guidelines and include steps such as identifying the research question, identifying relevant studies, selecting studies, charting the data, and collating and summarizing the results. The review will utilize databases, manual screening of additional sources, and covidence for study selection and data charting. The findings will be summarized using descriptive statistics and a descriptive synthesis of qualitative data. The review protocol has been registered with the Open Science Framework. RESULTS: The results of this scoping review will provide insights into different flash mob designs, motivations, and the data collection process, contributing to the development of high-quality flash mob data collections in healthcare research.

Intensive care unit nurses' perception of three different methods for delirium screening: A survey (DELIS-3).

BACKGROUND: Delirium is common in critically ill patients with detrimental effects in terms of increased morbidity, mortality, costs, and human suffering. Delirium detection and management depends on systematic screening for delirium, which can be challenging to implement in clinical practice. OBJECTIVES: The aim of this study was to explore how nurses in the intensive care unit perceived the use of Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), the Confusion Assessment Method for the Intensive Care Unit-7 (CAM-ICU-7), and Intensive Care Delirium Screening Checklist (ICDSC) for delirium screening of patients in the intensive care unit. METHODS: This was a cross-sectional, electronic-based survey of nurses' perceptions of delirium screening with the three different instruments for delirium screening. Nurses were asked to grade their perception of the usability of the three instruments and how well they were perceived to detect delirium and delirium symptom changes on a 1- to 6-point Likert scale. Open questions about perceived advantages and disadvantages of each instrument were analysed using the framework method. RESULTS: One hundred twenty-seven of 167 invited nurses completed the survey and rated the CAM-ICU-7 as faster and easier than the ICDSC, which was more nuanced and reflected changes in the patient's delirium better. Despite being rated as the fastest, easiest, and most used, the CAM-ICU provided less information and was considered inferior to the CAM-ICU-7 and ICDSC. Using familiar instruments made delirium screening easier, but being able to grade and nuance the delirium assessment was experienced as important for clinical practice. CONCLUSIONS: Both the ICDSC and the CAM-ICU-7 were perceived well suited for detection of delirium and reflected changes in delirium intensity. The CAM-ICU was rated as fast and easy but inferior in its ability to grade and nuance the assessment of delirium. Emphasis on clinical meaningfulness and continued education in delirium screening are necessary for adherence to delirium management guidelines.

Functional and cognitive rehabilitation interventions during intensive care admission: A protocol for a systematic integrative review.

BACKGROUND: Long-term cognitive impairment occurs in up to 60% of intensive care unit (ICU) survivors. Early use of functional and cognitive rehabilitation interventions, while patients are still in ICU, may reduce cognitive decline. We aim to describe the functional and cognitive interventions used during the ICU stay, the healthcare professionals providing interventions, and the potential impact on functional and cognitive rehabilitation. METHOD: In this integrative systematic review, we will include empirical qualitative, quantitative, mixed- and multiple-methods studies assessing the use of functional and cognitive rehabilitation provided in ICU. We will identify studies in relevant electronic databases from 2012 to 2022, which will be screened for eligibility by at least two reviewers. Literature reported as narrative reviews and editorials will be excluded. We will assess the impact of interventions evaluating a cognitive and functional function, quality of life, and all-cause mortality at 6-12 months after ICU discharge. The Revised Cochrane risk-of-bias Tool will be used for assessing risk of bias in clinical trials. For observational studies, we will use the National Institutes of Health Quality Assessment tool for Observational Cohort and Cross-Sectional Studies. Furthermore, we will use the critical appraisal skills programme for qualitative studies and the mixed methods appraisal tool for mixed methods studies. We will construct four matrices, including results describing which ICU patients and healthcare professionals were engaged in rehabilitation, which interventions were included in early rehabilitation in ICU, the potential impact on patient outcomes of rehabilitation interventions provided in ICU and a narrative synthesis of themes. A summary of the main results will be reported using modified GRADE methodology. IMPACT: This integrative review will inform the feasibility randomised clinical trial testing the development of a complex intervention targeting functional and cognitive rehabilitation for patients in ICU.

Intensive care professionals' perspectives on dysphagia management: A focus group study.

BACKGROUND: Intensive care unit (ICU)-acquired dysphagia has severe consequences for patients including increased morbidity and mortality. Standard operating procedures, however, including systematic evaluation of swallowing function and access to specialised assessment and training may be limited. Dysphagia management relies on multiprofessional collaboration, but practice is variable and nonstandardised. OBJECTIVE: The objective of this study was to explore and compare nurses', physicians', and occupational therapists' perceptions of dysphagia management in the ICU. MATERIALS AND METHODS: Six focus group interviews with 33 participants (23 nurses, four physicians, and six occupational therapists) were conducted and analysed using the framework method with a matrix developed from the first interview. Content from the interviews was plotted into the matrix, condensed, and refined. FINDINGS: Clinical dysphagia management depended on recognising signs of dysphagia in patients at risk. Assessment, therapeutic methods, and care differed among professional groups according to knowledge and roles. Interprofessional collaboration and responsibility for dysphagia management across the care continuum was determined by availability of resources, practical skills, knowledge, and formal decision-making competence and judged effective when based on mutual respect and recognition of healthcare professionals' different perspectives. CONCLUSION: Systematic interprofessional collaboration in ICU dysphagia management requires working towards a common goal of preventing aspiration and rehabilitating the patients' ability to swallow safely. This is based on dysphagia assessment, using appropriate therapeutic interventions, sharing knowledge, and improving skills among professional groups.

Defining dysphagia - a modified multi-professional Danish Delphi study.

OBJECTIVE: To establish a generally accepted Danish definition of dysphagia to enhance collaboration across sectors and professions. METHODS: The study was initiated by a multi-professional group of experienced researchers and board members of the Danish Society for Dysphagia. We used a modified Delphi methodology to achieve consensus among experienced health care professionals from different professions and contexts. The initial stage consisted of a literature search leading to the draft of different definitions followed by two Delphi rounds between professionals and a stakeholder consultation round. RESULTS: We conducted two Delphi rounds until one definition was clearly preferred. A total of 194 participants responded in round one, and 279 in round two. Both rounds had a broad representation of sectors and geography and most participants had worked with dysphagia for more than four years. CONCLUSION: The preferred definition was 'Dysphagia is a functional impairment that either prevents or limits the intake of food and fluids, and which makes swallowing unsafe, inefficient, uncomfortable or affects quality of life'. The definition was widely accepted among different health professional groups, patients and across sectors.

Humanizing and dehumanizing intensive care: Thematic synthesis (HumanIC).

BACKGROUND: Critical illness and the intensive care unit can be a terrifying experience to patients and relatives and they may experience the extreme life-saving measures as dehumanizing. Humanizing intensive care is often described as holism or dignity, but these abstract concepts provide little bodily resonance to what a humanized attitude is in concrete situations. OBJECTIVE: To explore what contributes to patients' and relatives' experience of intensive care as humanized or dehumanized. DESIGN: Thematic synthesis. MATERIALS: Findings from 15 qualitative papers describing patients' and/or relatives' perceptions of humanizing or dehumanizing care. METHODS: A systematic literature search of PubMed, CINAHL, Scopus and EMBASE from 1 January 1999 to 20 August 2022 identified 16 qualitative, empirical papers describing patients' and relatives' experiences of humanizing or dehumanizing intensive care, which were assessed using Critical Appraisal Skills Programme Qualitative Checklist, 15 papers were included and analysed using Thematic Synthesis and Ricoeur's model of the text. FINDINGS: Intensive care was humanized when patients felt connected with healthcare professionals, with themselves by experiencing safety and well-being and with their loved ones. Intensive care was humanized to relatives when the patient was cared for as a unique person, when they were allowed to stay connected to the patient and when they felt cared for in the critical situation. CONCLUSION: Patients and relatives experienced intensive care as humanized when healthcare professionals expressed genuine attention and supported them through their caring actions and when healthcare professionals supported patients' and relatives' opportunities to stay connected in the disrupted situation of critical illness. When healthcare professionals offered a connection to the patients and relatives, this helped them hold on and find meaning. PATIENT OR PUBLIC CONTRIBUTION: No patient and public contribution.

Translation and adaption of the Yale Swallow Protocol for a Danish intensive care setting.

BACKGROUND: Dysphagia related to intubation affects almost one in five patients in the intensive care unit; it may vary due to fluctuations in cerebral status and fatigue and lead to pneumonia, re-intubation and increased mortality. Taking care of patients' nutritional needs is an integral part of nursing and nurses must therefore be able to assess risk of dysphagia at all hours. However, Danish validated methods for use in the critically ill patient population are lacking. AIM: To translate and adapt the Yale Swallow Protocol method for implementation in a Danish intensive care unit setting. METHODS: Translation and adaption followed WHO's recommendations for translation and adaption of instruments. Face validity of the Danish version was evaluated in four group interviews. These were digitally recorded, transcribed and analysed using deductive content analysis. All interviewees gave informed consent. FINDINGS: The translated version of the Yale Swallow Protocol was easy to understand, although nurses needed to have the method explained and needed training in using the method. In addition, the Yale Swallow Protocol must be adapted to local practice in terms of identifying patients at risk of dysphagia and deciding where to document results of the screening. CONCLUSION: The translated version of the Yale Swallow Protocol proved conceptually and culturally sound and acceptable to intensive care unit nurses. Implementation should be followed by theoretical and practical training to build a nursing vocabulary relating to dysphagia and strengthen nurses' sensitivity to clinical manifestations consistent with dysphagia.

Effect of relatives' intensive care unit diaries on post traumatic stress in patients and relatives (DRIP-study): A mixed methods study.

AIM: To explore the relationship between psychological distress and diary sharing in patients and relatives, by investigating: 1) diary usage, 2) diary perception and 3) symptoms of psychological stress. DESIGN: Convergent mixed methods study. SETTING: Two intensive care units using patient diaries written by relatives with nurse guidance and shared with the patient after discharge. DATA: Self-reported scores of symptoms of posttraumatic stress, anxiety, depression and diary usage were crossed with qualitative description of diary usage and diary perception in 10 patients and 11 relatives. RESULTS: Most relatives expressed positive perceptions of diary usage; sharing the diary with the patient was related to fewer symptoms of posttraumatic stress. Patients had a positive perception of diary sharing, but symptoms of posttraumatic stress were unchanged. CONCLUSION: Reflecting on the tribulations of critical illness and later sharing reflections with the patient were related to lower rates of posttraumatic stress in relatives, suggesting that the act of writing and sharing a diary could have a protective effect. Delayed diary sharing did not have the same effect on patients but might enhance support between relatives and patients.

The effect of family-authored diaries on posttraumatic stress disorder in intensive care unit patients and their relatives: A randomised controlled trial (DRIP-study).

BACKGROUND: Critical illness and mechanical ventilation may cause patients and their relatives to experience symptoms of posttraumatic stress, anxiety, and depression due to fragmentation of memories of their intensive care unit (ICU) stay. Intensive care diaries authored by nurses may help patients and relatives process the experience and reduce psychological problems after hospital discharge; however, as patients particularly appreciate diary entries made by their relatives, involving relatives in authoring the diary could prove beneficial. OBJECTIVES: The objective of this study was to explore the effect of a diary authored by a close relative for a critically ill patient. METHODS: The study was a multicenter, block-randomised, single-blinded, controlled trial conducted at four medical-surgical ICUs at two university hospitals and two regional hospitals. Eligible for the study were patients ≥18 years of age, undergoing mechanical ventilation for ≥24 h, staying in the ICU ≥48 h, with a close relative ≥18 years of age. A total of 116 relatives and 75 patients consented to participate. Outcome measures were scores of posttraumatic stress symptoms, anxiety, depression, and health-related quality of life three months after ICU discharge. RESULTS: Relatives had 26.3% lower scores of posttraumatic stress in the diary group than in the control group (95% confidence interval: 4.8-% to 52.2%). Patients had 11.2% lower scores of posttraumatic stress symptoms in the diary group (95% confidence interval: -15.7% to 46.8%). There were no differences between groups in depression, anxiety, or health-related quality of life. CONCLUSION: A diary written by relatives for the ICU patient reduced the risk of posttraumatic stress symptoms in relatives. The diary had no effect on depression, anxiety, or health-related life quality. However, as the diary was well received by relatives and proved safe, the diary may be offered to relatives of critically ill patients during their stay in the ICU.

Intensive care unit diaries: Developing a shared story strengthens relationships between critically ill patients and their relatives: A hermeneutic-phenomenological study.

BACKGROUND: After discharge from the intensive care unit, patients and relatives struggle to rebuild their lives while suffering from fatigue and distress. Intensive care unit diaries written by relatives are a novel approach that may help relatives and patients process the critical illness experience together. OBJECTIVES: To explore patients' and relatives' perceptions and use of a diary written by relatives for the critically ill patient. DESIGN: Hermeneutical-phenomenological interview study. SETTING: Two regional mixed surgical/medical intensive care units in a regional hospital. PARTICIPANTS: 10 critically ill patients and 13 relatives. All participants were 18 years or older, all patients had undergone mechanical ventilation. METHODS: Dyadic, in-depth interviews conducted at 3-6 months and 8-16 months after discharge from the intensive care unit in 2015-2017. Interviews were analyzed using Ricoeur's theory of interpretation; a three-step process initiated by a naïve reading; followed by a structural analysis exploring the internal relations of the text, and finally, a critical interpretation to identify the most probable interpretation. RESULTS: Before sharing the intensive care unit diary, relatives had to feel able to give the diary to the patient, which meant separating themselves from the diary and being available for discussions with the patient. Likewise, the patients had to be prepared to receive the diary and to acknowledge relatives' efforts. Sharing the diary included interpreting the content of the diary, and developing a re-configured story based on the diary. CONCLUSION: The diary written by relatives for the critically ill patient was fulfilled when the diary was shared between the authoring relative and patient and a re-configured story was developed. This enabled a strengthened relationship between patient and relative. Not sharing could be disappointing to the relative, but did not preclude discussion of the experience of critical illness. This study provides professionals with knowledge about supporting patients and relatives through intensive care unit diaries written by relatives. Relatives need guidance on when to share the diary with the patient and how to accept patient rejection.

Structure and content of diaries written by close relatives for intensive care unit patients: A narrative approach (DRIP study).

AIM: To investigate structure and content of a nurse prompted diary written by relatives for intensive care unit (ICU) patients. DESIGN: A narrative analysis of ICU diaries. METHODS: From September 2015-August 2016, 12 diaries authored by 12 relatives for 12 ICU patients were sampled at 3-4 months post-ICU discharge. We used Ricoeur's hermeneutical phenomenology as a framework for a narrative analysis of the diaries. The first step was naïve reading, followed by structural analysis exploring the internal relations of the text. The structural analysis was broadened by exploring narrative structures. The last step was critical interpretation of the findings. FINDINGS: The diaries had a clear narrative structure; the diary-timeline consisted of: Pre-ICU phase, Early ICU phase, Culmination, Recovery and Post-ICU reflection. Three themes described the content of the diary: Struggling to get the story right for the patient; striving to understand what was happening and longing to re-establish a connection with the patient. Keeping a diary was perceived by the relatives as a challenging but rewarding task. CONCLUSION: The diary had the potential for reflection and a deeper understanding of the ICU stay. The diary served as a locus for patient and relatives to connect or re-connect, but some diaries might be too personal and emotional to share with the patient. Future research needs to explore advantages and disadvantages of ICU diaries authored by relatives.

The effect of diaries written by relatives for intensive care patients on posttraumatic stress (DRIP study): protocol for a randomized controlled trial and mixed methods study.

BACKGROUND: Critically ill patients and their relatives have complex needs for support during their stay in the intensive care unit (ICU) and the post-ICU rehabilitation period. Diaries written by nurses have proven beneficial for patients and relatives, preventing post-traumatic stress, anxiety and depression and helping patients and families find meaning. Actively involving relatives in writing a diary for critically ill patients is a new approach to helping relatives and patients cope; however, research is limited.The aim of this study is to test the hypothesis that a diary written by a close relative of a critically ill patient will reduce the risk of developing symptoms of post-traumatic stress disorder (PTSD) in the patient and relatives at 3 months post-ICU. Furthermore, the aim is to explore the perceptions and use of the diary and describe the diary content and structure. METHOD: The intervention consists of a hard-cover notebook that will be given to a close relative to write a diary for the critically ill patient while in the ICU. Guidance will be offered by ICU nurses on how to author the diary. The effect of the intervention will be tested in a two-arm, single-blind, randomized controlled trial, which aims to include 100 patient/relative pairs in each group. The primary outcome studied is symptoms of post-traumatic stress (PTSS-14). Secondary outcomes are scores on anxiety and depression (HADS) and the Medical Outcomes Study Questionnaire Short Form 36 (SF-36). The narrative structure and content of the diary as well as its use will be explored in two qualitative studies. DISCUSSION: The results of this study will inform ICU nurses about the effects, strengths and limitations of prompting relatives to author a diary for the patient. This will allow the diary intervention to be tailored to the individual needs of patients and relatives. TRIAL REGISTRATION: NCT02357680. Registered September 3, 2015.

Consolation or confrontation when interacting through an ICU diary - A phenomenological-hermeneutical study.

OBJECTIVES: Exploring relatives' experience of interaction with other relatives when writing a diary for the critically ill patient. RESEARCH METHODOLOGY: Qualitative interview data were analysed using a phenomenological-hermeneutical approach building on the theory of Ricoeur. SETTING: Seven relatives, who had written a diary when their close relative was admitted to the intensive care unit at a regional hospital in Denmark, were interviewed after the patient had been discharged. FINDINGS: Writing a diary for the critically ill patient implied creating the story together, which impacted the relationships of the relatives. However, the relationship between relatives determined who might author the diary and also the content of the diary. Authoring the diary could be both a powerful position to shape the story unfolding in the diary or a burdensome responsibility. CONCLUSION: Authorship of the diary provided relatives with the power to influence the narrative in the diary. Co-authoring the diary allowed the relatives to incorporate the illness experience into a personal narrative, thereby influencing the formation of a family narrative. However, difficult relationships kept relatives from sharing emotions and understandings and could cause suffering among relatives and co-creation of the diary to fail.