PRACTICE: Development of a Core Outcome Set for Trials of Physical Rehabilitation in Critical Illness.

Rationale Findings from individual trials of physical rehabilitation interventions in critically ill adults have limited potential for meta-analysis and informing clinical decision-making due to heterogeneity in selection and reporting of outcomes used for evaluation. Objective The objective of this study was to determine a core outcome set (COS) for use in all future trials evaluating physical rehabilitation interventions delivered across the critical illness continuum of recovery. Methods An international, two-round, online, modified Delphi consensus process, following recommended standards, was conducted. Participants (N=329) comprised three stakeholder groups (Researchers, n=58 (18%); Clinicians, n=247 (75%); Patients and Caregivers, n=24 (7%)), and represented 26 countries and 9 healthcare professions. Participants rated the importance of a range of relevant outcomes. Outcomes included in the COS were those prioritised of "critical importance" by all three stakeholder groups. Results Survey response rates were 88% (Round 1) and 91% (Round 2). From a total of 32 initial outcomes, the following outcomes reached consensus for inclusion in the COS: Physical Function, Activities of Daily Living, Survival, Health-related Quality of Life, Exercise Capacity, Cognitive Function, Emotional and Mental Wellbeing, and Frailty. Conclusion This study developed a consensus-generated COS for future clinical research evaluating physical rehabilitation interventions in critically ill adults across the continuum of recovery. Ascertaining recommended measurement instruments for these core outcomes is now required to facilitate implementation of the COS. This article is open access and distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).

Eye movement desensitisation and reprocessing for survivors of life-threatening medical events.

OBJECTIVES: This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of eye movement desensitisation and reprocessing (EMDR), a psychological intervention programme, on symptoms related to traumatic stress in survivors of life-threatening medical events. SECONDARY OBJECTIVES: to evaluate whether the effects of EMDR differ according to the nature of the medical event (associated diagnosis or setting), measured outcome (post-traumatic stress disorder (PTSD), anxiety, depression, or quality of life), or intervention (online, face-to-face, group or individual sessions).

Using patient and care partner experiences to confirm outcomes of relevance for inclusion in a core outcome set for trials of physical rehabilitation in critical illness: A qualitative interview study.

BACKGROUND: Incorporating the perspectives of patients and care partners is crucial in the development of core outcome sets. One effective approach for achieving this involvement is by seeking input to refine the outcomes for consensus. The objectives of the study were to: i) to determine patient and care partner views on outcomes that should be measured in trials of physical rehabilitation interventions across the critical illness recovery continuum; (ii) to map these views with a pre-established list of thirty outcomes for potential inclusion in a core outcome set for these trials; and (iii) to identify any new outcomes that could be considered for inclusion. METHODS: A qualitative semistructured telephone interview study was conducted with a convenience sample of post-critical illness patients and care partners, as part of core outcome set development work. Anonymised interview transcripts were analysed using a framework approach, and exemplary narrative quotes from participants were reported used to illustrate outcome reporting. FINDINGS: Fourteen participants were recruited (male:female ratio = 8:6, age range [minimum-maximum]: 50-80 years, 13 former patients, one spouse). Time since intensive care unit discharge ranged from less than 1 year to 10 years at the time of interview. Participants described a range of outcomes that could be measured in trials of physical rehabilitation after critical illness that mapped closely with the pre-established list. No new outcomes were introduced by participants during the interviews. Experiences described by participants commonly reflected outcomes related to physical ability and performance, functional level, activities of daily living, and emotional and mental wellbeing. Participants spoke to how the different outcomes directly impacted their day-to-day lives and highlighted their priorities centred around resumption of tasks and activities that had value to them at personal, functional, and societal level. CONCLUSION: Qualitative interviews confirmed the relevance of existing outcomes for potential inclusion in a core outcome set for trials of physical rehabilitation interventions across the critical illness recovery continuum. The added significance of our findings is to provide real-world meaning to these outcomes. REGISTRATION: COMET Initiative, ID288, https://www.comet-initiative.org/studies/details/288.

Evaluating the usefulness of a wordless picture book for adults with intellectual disabilities about the COVID-19 vaccination programme using co-production: The CAREVIS study.

AIM: To explore the usefulness of a co-designed wordless book showing processes of receiving COVID-19 vaccines designed by, and for, adults with intellectual disabilities. METHODS: A qualitative evaluation of the resource using mixed methods. Semi-structured interviews were conducted with people with intellectual disabilities, carers and health professionals about resource content, and use. This was analysed thematically. A survey was circulated to intellectual disabilities networks to understand resource need, use, sharing and content. RESULTS: Understanding the COVID-19 vaccine was a process, not a single event using one resource. A visual resource had a place in facilitating conversations about vaccines between people with intellectual disabilities and carers. Differing perspectives were expressed regarding personal needs, existing awareness of vaccine programmes and communication preferences. Changes were suggested to improve the suggested storyline and relevance around COVID-19 restrictions changing. CONCLUSION: A visual resource may help conversations about the COVID-19 vaccine for people with intellectual disabilities.

Treating insomnia in people who are incarcerated: a feasibility study of a multicomponent treatment pathway.

Around 60% of people who are incarcerated have insomnia; 6-10 times more prevalent than the general population. Yet, there is no standardized, evidence-based approach to insomnia treatment in prison. We assessed the feasibility of a treatment pathway for insomnia in a high-secure prison to inform a future randomized controlled trial (RCT) and initial efficacy data for sleep and mental health outcomes. We used a within-participants pre-post design. The stepped-care pathway included: self-management with peer support, environmental aids, and cognitive behavioral therapy for insomnia (CBTi). Assessment measures for insomnia, well-being, mood, anxiety, suicidality, overall health, sleepiness, fatigue, and cognitive functioning were administered at baseline and pathway exit. Feasibility criteria included eligibility to participate, CBTi uptake, and assessment completion. Forty-two adult males who are incarcerated were approached of which 95.2% were eligible. Of those deemed eligible, most participated (36/40, 90.0%). Most who completed baseline completed post-assessments (28/36, 77.8%) and of these, most showed improvements in their subjective sleep (27/28, 96.4%). Large reductions were found from pre- to posttreatment in insomnia severity (d = -1.81, 95% CI: 8.3 to 12.9) and 57.0% reported no clinically significant insomnia symptoms at post-assessment. There was no overall change in actigraphy-measured sleep. Large treatment benefits were found for depression, anxiety, well-being, and cognitive functioning, with a medium benefit on suicidal ideation. The treatment pathway for insomnia in prison was feasible and may be an effective treatment for insomnia in people who are incarcerated, with additional promising benefits for mental health. A pragmatic RCT across different prison populations is warranted. This paper is part of the Sleep and Circadian Health in the Justice System Collection.

Mixed-methods randomised study exploring the feasibility and acceptability of eye-movement desensitisation and reprocessing for improving the mental health of traumatised survivors of intensive care following hospital discharge: protocol.

INTRODUCTION: Post-traumatic symptoms are common among patients discharged from intensive care units (ICUs), adversely affecting well-being, increasing healthcare utilisation and delaying return to work. Non-pharmacological approaches (eg, music, therapeutic touch and patient diaries) have been suggested as candidate interventions and trauma-focused psychological interventions have been endorsed by international bodies. Neither category of intervention is supported by definitive evidence of long-term clinical effectiveness in patients who have been critically ill. This study assesses the feasibility and acceptability of using eye-movement desensitisation and reprocessing (EMDR) to improve the mental health of ICU survivors. METHODS AND ANALYSIS: EMERALD is a multicentre, two-part consent, pilot feasibility study, recruiting discharged ICU survivors from three hospitals in the UK. We are gathering demographics and measuring post-traumatic symptoms, anxiety, depression and quality of life at baseline. Two months after discharge, participants are screened for symptoms of post-traumatic stress disorder (PTSD) using the Impact of Events Scale-Revised (IES-R). Patients with IES-R scores<22 continue in an observation arm for 12 month follow-up. IES-R scores≥22 indicate above-threshold PTSD symptoms and trigger invitation to consent for part B: a randomised controlled trial (RCT) of EMDR versus usual care, with 1:1 randomisation. The study assesses feasibility (recruitment, retention and intervention fidelity) and acceptability (through semistructured interviews), using a theoretical acceptability framework. Clinical outcomes (PTSD, anxiety, depression and quality of life) are collected at baseline, 2 and 12 months, informing power calculations for a definitive RCT, with quantitative and qualitative data convergence guiding RCT refinements. ETHICS AND DISSEMINATION: This study has undergone external expert peer review and is funded by the National Institute for Health and Care Research (grant number: NIHR302160). Ethical approval has been granted by South Central-Hampshire A Research Ethics Committee (IRAS number: 317291). Results will be disseminated through the lay media, social media, peer-reviewed publication and conference presentation. TRIAL REGISTRATION NUMBER: NCT05591625.

Remaking critical care: Place, body work and the materialities of care in the COVID intensive care unit.

In this article, we take forward sociological ways of knowing care-in-practice, in particular work in critical care. To do so, we analyse the experiences of staff working in critical care during the first wave of the COVID-19 pandemic in the UK. This moment of exception throws into sharp relief the ways in which work and place were reconfigured during conditions of pandemic surge, and shows how critical care depends at all times on the co-constitution of place, practices and relations. Our analysis draws on sociological and anthropological work on the material culture of health care and its sensory instantiations. Pursuing this through a study of the experiences of 40 staff across four intensive care units (ICUs) in 2020, we provide an empirical and theoretical elaboration of how place, body work and care are mutually co-constitutive. We argue that the ICU does not exist independently of the constant embodied work of care and place-making which iteratively constitute critical care as a total system of relations.

Adaptations to research within the intellectual disability population during the COVID-19 pandemic: Lessons learned from the CAREVIS study.

The COVID-19 pandemic resulted in changes in all areas of clinical practice, including clinical research and within the intellectual disability population. While there have been some benefits from this rapid adoption of change, those involved in research have had to overcome a number of additional challenges. These adaptive changes, which have included the use of technology, closure of social spaces, working with specific groups who are more vulnerable to COVID-19, and mask use impairing communication, have had both positive and negative impacts on research. As the pandemic and related restrictions evolve, it is important to examine the changes that have occurred. In the future, the adoption of a hybrid model in research is likely to be a common approach, establishing a balance between technology and in-person interaction.

An aromatherapy massage intervention on sleep in the ICU: A randomized controlled feasibility study.

We conducted a feasibility randomized controlled trial exploring the effect of aromatherapy massage on sleep in critically ill patients. Patients were randomized to receive aromatherapy massage or usual care, and feasibility of recruitment and outcome data completion was captured. Sleep (depth) was assessed through Bispectral Index monitoring and self/nurse-reported Richards-Campbell Sleep Questionnaires, and the Sleep in the ICU Questionnaire. Thirty-four patients participated: 17 were randomized to aromatherapy massage and 17 to control. Five participants who received the intervention completed outcomes for analysis (alongside eight controls). A larger study was deemed unfeasible in this population, highlighting the value of testing feasibility of complex interventions, such as massage for sleep in ICU.

Reflective learning conversations model for simulation debriefing: a co-design process and development innovation.

BACKGROUND: Health practitioners must be equipped with effective clinical reasoning skills to make appropriate, safe clinical decisions and avoid practice errors. Under-developed clinical reasoning skills have the potential to threaten patient safety and delay care or treatment, particularly in critical and acute care settings. Simulation-based education which incorporates post-simulation reflective learning conversations as a debriefing method is used to develop clinical reasoning skills while patient safety is maintained. However, due to the multidimensional nature of clinical reasoning, the potential risk of cognitive overload, and the varying use of analytic (hypothetical-deductive) and non-analytic (intuitive) clinical reasoning processes amongst senior and junior simulation participants, it is important to consider experience, competence, flow and amount of information, and case complexity related factors to optimize clinical reasoning while attending group- based post-simulation reflective learning conversations as a debriefing method. We aim to describe the development of a post-simulation reflective learning conversations model in which a number of contributing factors to achieve clinical reasoning optimization were addressed. METHODS: A Co-design working group (N = 18) of doctors, nurses, researchers, educators, and patients' representatives collaboratively worked through consecutive workshops to co-design a post-simulation reflective learning conversations model to be used for simulation debriefing. The co-design working group established the model through a theoretical and conceptual-driven process and multiphasic expert reviews. Concurrent integration of appreciative inquiry, plus/delta, and Bloom's Taxonomy methods were considered to optimize simulation participants' clinical reasoning while attending simulation activities. The face and content validity of the model were established using the Content Validity Index CVI and Content Validity Ratio CVR methods. RESULTS: A Post-simulation reflective learning conversations model was developed and piloted. The model was supported with worked examples and scripted guidance. The face and content validity of the model were evaluated and confirmed. CONCLUSIONS: The newly co-designed model was established in consideration to different simulation participants' seniority and competence, flow and amount of information, and simulation case complexity. These factors were considered to optimize clinical reasoning while attending group-based simulation activities.

A randomised pilot feasibility study of eye movement desensitisation and reprocessing recent traumatic episode protocol, to improve psychological recovery following intensive care admission for COVID-19.

Background: Approximately 50% of intensive care survivors experience persistent psychological symptoms. Eye-movement desensitisation and reprocessing (EMDR) is a widely recommended trauma-focussed psychological therapy, which has not been investigated systematically in a cohort of intensive care survivors: We therefore conducted a randomised pilot feasibility study of EMDR, using the Recent Traumatic Episode Protocol (R-TEP), to prevent psychological distress in intensive care survivors. Findings will determine whether it would be possible to conduct a fully-powered clinical effectiveness trial and inform trial design. Method: We aimed to recruit 26 patients who had been admitted to intensive care for over 24 h with COVID-19 infection. Consenting participants were randomised (1:1) to receive either usual care plus remotely delivered EMDR R-TEP or usual care alone (controls). The primary outcome was feasibility. We also report factors related to safety and symptom changes in post-traumatic stress disorder, (PTSD) anxiety and depression. Results: We approached 51 eligible patients, with 26 (51%) providing consent. Intervention adherence (sessions offered/sessions completed) was 83%, and 23/26 participants completed all study procedures. There were no attributable adverse events. Between baseline and 6-month follow-up, mean change in PTSD score was -8 (SD = 10.5) in the intervention group versus +0.75 (SD = 15.2) in controls (p = 0.126). There were no significant changes to anxiety or depression. Conclusion: Remotely delivered EMDR R-TEP met pre-determined feasibility and safety objectives. Whilst we achieved group separation in PTSD symptom change, we have identified a number of protocol refinements that would improve the design of a fully powered, multi-centre randomised controlled trial, consistent with currently recommended rehabilitation clinical pathways. Trial registration: ClinicalTrials.gov: NCT04455360.

A protocol for a scoping review of the use of mental simulation and full-scale simulation in practising healthcare decision-making skills of undergraduate nursing students.

AIM: This scoping review aims to explore the effect of FSS and mental simulation on the decision-making skills of nursing students. BACKGROUND: Full-scale simulation (FSS) has been the most used simulation modality in nursing education due to its applicability to enhance both technical and non-technical skills. However, FSS can be excessively costly and other factors such as technophobia and lack of trained staff and support make FSS less accessible, especially for nursing education. Therefore, a novel mental simulation that is interactive and supported by visual elements can be a substitute for FSS, at least for some of the skills, such as clinical decision-making. Reviews comparing the effectiveness of FSS and mental simulation on decision-making skills in nursing students are lacking. Further knowledge on the effectiveness of these two modalities on decision-making skills for nursing students is needed to inform the nursing education curriculum and to decide between the two modalities. DESIGN: This protocol adheres to the guidelines outlined in the PRISMA extension for scoping reviews (PRISMA-scr) checklist. METHOD: The methodological framework for scoping reviews will be followed for this scoping review. Scopus, EBSCOhost the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE and for the grey literature ERIC and BASE will be searched for related studies. The search will be limited to January 2008 and April 2023 (up-to-date) and English. A detailed search strategy was developed with an experienced research information manager and this strategy will be adapted to each database. A single screening will be performed by an author who will screen all abstracts and titles and full-text publications. After the study selection step of the framework, the data from the included studies will be charted using a data extraction form. The data will be synthesised by comparing the effect of FSS and mental simulation on decision-making skills. CONCLUSION: A synopsis of the publication on FSS and mental simulation on nurse students' decision-making skills will be useful for stakeholders when choosing between two modalities to deliver decision-making skills to nursing students and also help to inform the nursing education and simulation practice. SCOPING REVIEW REGISTRATION: Protocols.io (doi: 10.17504/protocols.io.e6nvw57y7vmk/v1).

Driving resumption after critical illness:A survey and framework analysis of patient experience and process.

Background: Adverse sequelae are common in survivors of critical illness. Physical, psychological and cognitive impairments can affect quality of life for years after the original insult. Driving is an advanced task reliant on complex physical and cognitive functioning. Driving represents a positive recovery milestone. Little is currently known about the driving habits of critical care survivors. The aim of this study was to explore the driving practices of individuals after critical illness. Methods: A purpose-designed questionnaire was distributed to driving licence holders attending critical care recovery clinic. Results: A response rate of 90% was achieved. 43 respondents declared their intention to resume driving. Two respondents had surrendered their licence on medical grounds. 68% had resumed driving by 3 months, 77% by 6 months, and 84% by 1 year. The median interval (range) between critical care discharge and resumption of driving was 8 weeks (1-52 weeks). Psychological, physical and cognitive barriers were cited by respondents as barriers to driving resumption. Eight themes regarding driving resumption were identified from the framework analysis under three core domains and included: psychological/cognitive impact on ability to drive (Emotional readiness and anxiety; Confidence; Intrinsic motivation; Concentration), physical ability to drive (Weakness and fatigue; Physical recovery), and supportive care and information needs to resume driving (Information/advice; Timescales). Conclusion: This study demonstrates that resumption of driving following critical illness is substantially delayed. Qualitative analysis identified potentially modifiable barriers to driving resumption.

Assessment of Clinical Reasoning While Attending Critical Care Postsimulation Reflective Learning Conversation: A Scoping Review.

BACKGROUND: The critical care environment is characterized with a high level of workload, complexity, and risk of committing practice mistakes. To avoid clinical errors, health care professionals should be competent with effective clinical reasoning skills. To develop effective clinical reasoning skills, health care professionals should get the chance to practice and be exposed to different patient experiences. To minimize safety risks to patients and health care professionals, clinical reasoning with a focus on reflective learning conversation opportunities can be practiced in simulated settings. OBJECTIVES: To explore the most valid and reliable tools to assess clinical reasoning while attending adult critical care-related simulation-based courses in which reflective learning conversations are used. METHODS: A scoping review was conducted following Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews Extension for Scoping Reviews. Eight electronic databases were searched, and full-text review was completed for 26 articles. RESULTS: The search resulted in no studies conducted to measure clinical reasoning while attending adult critical care-related, simulation-based courses in which the reflective learning conversation method was embedded. DISCUSSION: This highlights the need to evaluate current available clinical reasoning tools or develop new tools within the context of adult critical care simulation where reflective learning forms a key part of the simulation procedures.

Compassionate, collective or transformational nursing leadership to ensure fundamentals of care are achieved: A new challenge or non-sequitur?

AIMS: This discursive paper draws on three key leadership theories with the aim of outlining how styles of leadership impact the provision of fundamentals of care. DESIGN: Discussion paper. DATA SOURCES: key leadership theories, leadership and fundamentals of care literature. IMPLICATIONS FOR NURSING: The conceptualization of fundamentals of care is viewed through the lens of nursing leadership, and collective, compassionate and transformational leadership theory. The cognitive dissonance that nursing leaders encounter when trying to reconcile organizational, patient and nurses' needs is considered, and the pressure to deliver high-quality fundamentals of care presents a challenge to nurse leaders. CONCLUSION: Leaders must align nursing and patient outcome data to drive forward and prioritize fundamental care. Focusing on key elements of relational leadership styles will ensure a workforce fit to provide fundamental care, which in the current climate must be an organizational and global nursing priority. IMPACT: This discussion attempts to draw together overlapping leadership theories, emphasizes the importance of relational leadership in ensuring the provision of the fundamentals of care and acknowledged the impact of the COVID-19 pandemic on nurses and nursing care, with leadership implications outlined, such as a need for role-modelling, understanding shared values and giving nurses a voice. It will have an impact on nurse leaders, but also on those nurses providing direct care by issuing a challenge for them to confront their own nurse leaders, and to ask that they better resolve competing needs of both the nursing workforce and patients.

Chronic illness and critical care-A qualitative exploration of family experience and need.

BACKGROUND: People with chronic illnesses such as cancer and cardiovascular disease are living longer and often require the support of critical care services. Current health care provision means patients may be discharged home once clinically stable despite still having high care demands including social, emotional, or physical needs. Families are often required to assume caregiving roles. Research into family burden using quantitative methods has increased awareness, however, little qualitative work exists and the development of support interventions for families is required. AIMS: To explore the experience and needs of family members of people with an existing chronic illness who are admitted to the Critical Care Unit (CCU), and to identify the desired components of a family support intervention in the form of a resource toolkit. STUDY DESIGN: A qualitative exploration of family experience and need, and content development for a resource toolkit using focus group methodology. Two focus groups and one face-to-face interview were conducted involving nine adult (≥18 years) family members of adult patients with chronic illness admitted to critical care in the preceding 9 months across two specialist hospitals in the UK. These were digitally recorded, transcribed, and thematically analysed. RESULTS: Four themes were identified: importance of communication, need for support, trauma of chronic illness, and having to provide "Do-it-Yourself" care. The immense responsibility of families to provide care throughout the illness trajectory is highlighted. Understandable information is essential for a family support toolkit. CONCLUSION: Family members often view a critical care episode broadly from diagnosis through to recovery/rehabilitation. Basic communication training skills within critical care should be ensured, alongside coordination of simple solutions. The potential traumatic impact on families should be highlighted early within the pathway, and positive aspects used to harness essential family support. A simple and coordinated approach to a toolkit is preferred. RELEVANCE TO CLINICAL PRACTICE: This study highlights that a critical care experience may impact broadly beyond CCU, and the importance of informing patients and families of this potential experience, prior to or on admission, to aid preparation. Further highlighted is the need for contemporaneous and accurate information from clinicians involved in care. Families report a better experience when there is good collaboration across critical care services and admitting clinical teams. Early involvement of families in overall discharge planning is essential to allow patients and families to adjust and plan for recovery.

Learning from stakeholders to inform good practice guidance on consent to research in intensive care units: a mixed-methods study.

OBJECTIVES: Obtaining informed consent from patients in intensive care units (ICUs) prior to enrolment in a study is practically and ethically complex. Decisions about the participation of critically ill patients in research often involve substitute decision makers (SDMs), such as a patient's relatives or doctors. We explored the perspectives of different stakeholder groups towards these consent procedures. DESIGN AND METHODS: Mixed-methods study comprising surveys completed by ICU patients, their relatives and healthcare practitioners in 14 English ICUs, followed by qualitative interviews with a subset of survey participants. Empirical bioethics informed the analysis and synthesis of the data. Survey data were analysed using descriptive statistics of Likert responses, and analysis of interview data was informed by thematic reflective approaches. RESULTS: Analysis included 1409 survey responses (ICU patients n=333, relatives n=488, healthcare practitioners n=588) and 60 interviews (ICU patients n=13, relatives n=30, healthcare practitioners n=17). Most agreed with relatives acting as SDMs based on the perception that relatives often know the patient well enough to reflect their views. While the practice of doctors serving as SDMs was supported by most survey respondents, a quarter (25%) disagreed. Views were more positive at interview and shifted markedly depending on particularities of the study. Participants also wanted reassurance that patient care was prioritised over research recruitment. Findings lend support for adaptations to consent procedures, including collaborative decision-making to correct misunderstandings of the implications of research for that patient. This empirical evidence is used to develop good practice guidance that is to be published separately. CONCLUSIONS: Participants largely supported existing consent procedures, but their perspectives on these consent procedures depended on their perceptions of what the research involved and the safeguards in place. Findings point to the importance of explaining clearly what safeguards are in place to protect the patient.

What matters most to adults with a tracheostomy in ICU and the implications for clinical practice: a qualitative systematic review and metasynthesis.

PURPOSE: Tracheostomy is a common surgical procedure in ICU. Whilst often life-saving, it can have important impacts on patients. Much of the literature on tracheostomy focuses on timing and technique of insertion, risk factors and complications. More knowledge of patient experience of tracheostomy in ICU is needed to support person-centred care. MATERIALS AND METHODS: Qualitative systematic review and metasynthesis of the literature on adult experience of tracheostomy in ICU. Comprehensive search of four bibliographic databases and grey literature. Title and abstract screening and full text eligibility was completed independently by two reviewers. Metasynthesis was achieved using thematic synthesis, supported by a conceptual framework of humanised care. RESULTS: 2971 search returns were screened on title and abstract and 127 full texts assessed for eligibility. Thirteen articles were included for analysis. Five descriptive and three analytical themes were revealed. The over-arching theme was 'To be seen and heard as a whole person'. Patients wanted to be treated as a human, and having a voice made this easier. CONCLUSIONS: Voice restoration should be given high priority in the management of adults with a tracheostomy in ICU. Staff training should focus on both technical skills and compassionate care to improve person-centred outcomes.

Informing the standardising of care for prolonged stay patients in the intensive care unit: A scoping review of quality improvement tools.

OBJECTIVES: To inform design of quality improvement tools specific to patients with prolonged intensive care unit stay, we determined characteristics (format/content), development, implementation and outcomes of published multi-component quality improvement tools used in the intenisve care unit irrespective of length of stay. RESEARCH METHODOLOGY: Scoping review searching electronic databases, trial registries and grey literature (January 2000 to January 2022). RESULTS: We screened 58,378 citations, identifying 96 studies. All tools were designed for use commencing at intensive care unit admission except three tools implemented at 3, 5 or 14 days. We identified 32 studies of locally developed checklists, 28 goal setting/structured communication templates, 23 care bundles and 9 studies of mixed format tools. Most (43 %) tools were designed for use during rounds, fewer tools were designed for use throughout the ICU day (27 %) or stay (9 %). Most studies (55 %) reported process objectives i.e., improving communication, care standardisation, or rounding efficiency. Most common clinical processes quality improvement tools were used to standardise were sedation (62, 65 %), ventilation and weaning (55, 57 %) and analgesia management (58, 60 %). 44 studies reported the effect of the tool on patient outcomes. Of these, only two identified a negative effect; increased length of stay and increased days with pain and delirium. CONCLUSION: Although we identified numerous quality improvement tools for use in the intensive care unit, few were designed to specifically address actionable processes of care relevant to the unique needs of prolonged stay patients. Tools that address these needs are urgently required. SYSTEMATIC REVIEW REGISTRATION: The review protocol is registered on the Open Science Framework, https://osf.io/, DOI 10.17605/OSF.IO/Z8MRE.