Patients' perceptions of and emotional outcome after intensive care: results from a multicentre study.

BACKGROUND: Recovery from critical illness can be prolonged and can result in a number of significant short- and long-term psychological consequences. These may be associated with the patient's perception of the intensive care experience. AIM: The aims of the study were to assess patients' perceptions of their intensive care unit (ICU) experience and the effect of these on anxiety, depression and post-traumatic stress up to 6 months after discharge. METHOD: One hundred and three participants were recruited from six ICUs from one Critical Care Network in the United Kingdom. A prospective, longitudinal study was designed to assess anxiety, depression, post-traumatic stress symptomatology and patients' perceptions of their intensive care experience. Data were collected on three occasions: after intensive care discharge and before hospital discharge, and 2 months and 6 months later. Measures included the impact of events scale, hospital anxiety and depression scale and intensive care experience questionnaire. RESULTS: Anxiety, depression, avoidance and intrusion scores did not significantly reduce over time. At hospital discharge there was a significant association between patients' perceptions of their intensive care experience and anxiety, depression, avoidance and intrusion scores at hospital discharge. CONCLUSION: Standardised assessment of an intensive care experience is important. It provides information about the patient experience which can inform care practice within ICU, following discharge to the ward and, in the longer term, rehabilitation.

Weaning from ventilation needs to be tailored to individual patients and involve them.

AIM: To improve understanding of how nurses use technology to wean patients from mechanical ventilation. BACKGROUND: The literature tends to focus on weaning indices, predictors of success or weaning methods. Few papers address patients' experiences of weaning. DESIGN: An ethnographic approach was adopted to understand how nurses used technology to wean patients from ventilation. METHODS: Data was gathered by participant observation and interviews over six months. In total, 250 hours of field notes were recorded. RESULTS: Data was analysed using the content analysis method. A central theme of knowing the patient was identified, as well as three sub-themes: ways of knowing; continuity of care; and patients' role in the weaning trajectory. CONCLUSION: Participants implied during interviews that "knowing the patient" was essential to delivering patient centred care. Two main factors are necessary for nurses to know their patients: continuity of care and expertise. "Ways of knowing" relied on gaining information about patients and their role as passive recipients of treatment. IMPLICATIONS FOR PRACTICE: Staff allocation systems should enable them to learn from experienced nurses, while work schedules should be organised to ensure nurses begin weaning when they can offer continuity of care. Knowing the patient has been defined as a characteristic of expert nursing. To be truly patient centred, nurses need to address the barriers that prevent them from getting to "know" patients.

The patient safety collaborative programme: opportunities for physician engagement.

Driving improvements in patient safety has been a core goal of the Academic Health Science Networks (AHSNs) in England since their inception in 2013. The National Patient Safety Collaborative Programme, nested within the 15 geographically located AHSNs, was established in 2014 in response to the Berwick review. In 2019, the new NHS national patient safety strategy was published, which placed the AHSNs as a key vehicle for delivering its ambitions. This paper explores the achievements of, and opportunities presented by, the collaborative in addressing some of the key patient safety challenges facing physicians and their wider teams. Case studies illustrate the AHSNs' contribution to support national ambitions, including the adoption of the National Early Warning Score (NEWS) 2, and the impact of regionally-led work on patient outcomes, such as reducing mortality from sepsis and acute kidney injury. We set out current activities, opportunities for physician engagement and plans for future work.

The role of technology in critical care nursing.

AIM: This paper is a report of a study to identify the meaning for critical care nurses of technology related to weaning from mechanical ventilation and to explore how that technology was used in practice. BACKGROUND: The literature concerned with the development of critical care (intensive care and high dependency units) focuses mainly on innovative medical technology. Although this use of technology in critical care is portrayed as new, it actually represents a transfer of technology from operating theatres. METHOD: An ethnographic study was conducted and data were collected on one critical care unit in a large teaching hospital over a 6-month period in 2004. The methods included participant observation, interviews and the collection of field notes. FINDINGS: The overall theme 'The nursing-technology relation' was identified. This comprised three sub-themes: definition of technology, technology transferred and technology transformed. Novice nurses took a task-focussed approach to weaning, treating it as a 'medical' technology transferred to them from doctors. Expert nurses used technology differently and saw its potential to become a 'nursing technology'. CONCLUSION: Nurses need to examine how they can adapt and to 'reconfigure' technology so that it can be transformed into a nursing technology. Those technologies that do not fit with nursing may have no place there. Rather than simply extending and expanding their roles through technology transfer, nurses should transform those technologies that preserve the essence of nursing and can contribute to a positive outcome for patients.

Weaning from ventilation--current state of the science and art.

Weaning from mechanical ventilation has attracted a growing interest recently in the medical and nursing press. Attempts have been made to determine a patient's readiness to wean, define criteria for successful weaning and enhance the weaning process through the developments of protocols. Key to this work is the role of the critical care nurse. Transferring the role and the responsibility of weaning from the traditional perspective of the intensivist to the nurse is not without challenges. Inherent is the need for skill and expertise and the willingness to accept this level of responsibility, not questioned in the medical role, but worthy of consideration when transferred to nurses. Key to successful weaning and weaning is redefined for the purposes of this paper, is continuity of care, knowing the patient and the development of patient-centred, individualized weaning plans. Critical care nurses have an important role to play. This is particularly so when the patient experience is to be understood. There is relatively little research conducted in this area, yet this is an important consideration if we are to fully understand and embrace the role of patients in their weaning. Weaning in the context of critical care can be challenging. To wean the difficult-to-wean or the long-term-weaning patient requires great skill and expertise. Expertise in this context has not been fully explored, yet research suggests that these patients are not allocated expert nurses to care for them because they are not seen as critically ill. It may be that this group of patients would benefit from a transfer to a weaning centre as suggested by the Modernisation Agency in 2002. This would greatly challenge the way we, as critical care nurses, perceive weaning in critical care.

The importance of knowing the patient in weaning from mechanical ventilation.

AIM: The aim of the research was to understand how nurses used technology to wean patients from mechanical ventilation. BACKGROUND: The literature concerned with the development of critical care centres on the role of technology with little emphasis on the nursing contribution. DESIGN: An ethnographic approach was used to understand how nurses used technology to wean patients from mechanical ventilation. METHODS: Data were gathered by participant observation and interviewing over a 6-month period. In total, 250 h of field notes were recorded. RESULTS: Data were analysed by the content analysis method. Knowing the patient was a central theme identified. Three sub-themes were identified: ways of knowing, continuity of care and the role of the patient in the weaning trajectory. CONCLUSION: 'Knowing the patient' was implied during the interviews as essential to the delivery of patient-centred care. There were two main factors that needed to be present in order for nurses to know their patients: continuity of care and expertise. 'Ways of knowing' was reliant on gaining information about the patient. The role of the patient was a passive recipient of treatment. IMPLICATIONS FOR PRACTICE: Knowing the patient has been defined as a characteristic of expert nursing. To be truly patient-centred nursing needs to address the barriers that prevent nurses from getting to 'know' their patients.

Following the patient journey to improve medicines management and reduce errors.

Patient safety is a major concern in the NHS, and medicines management is a vital aspect of this. This article describes one patient's journey through healthcare from the perspective of how medicines are managed. The patient's journey starts with an emergency admission to hospital, followed by a 10 day inpatient stay, including a brief stay in the high dependency unit, through to discharge. Adverse events or near misses are highlighted, showing key areas where nurses need to take action to ensure or improve patient safety.

Weaning from ventilation: does a care bundle approach work?

There has been renewed interest in weaning from mechanical ventilation in critical care since the publication of the Modernisation Agency paper in 2002. There have been many papers reporting ways of improving the weaning process but these are specific to single elements and neglect the contextual issues that influence the weaning process. Care bundles have been introduced nationally to standardise patient care and improve patient outcome. Examples in critical care are the ventilator care bundle and sepsis care bundle. However, since care bundles have become linked with targets and part of the 10 High Impact Changes there is a tendency to want to call everything a care bundle. A care bundle is a small but critical set of processes that when implemented together improve outcome. One critical care network has written a weaning care bundle. This is an example of a service improvement initiative the aim of which was to improve weaning from mechanical ventilation. This paper reviews this approach and presents results from a pilot in one teaching hospital.

The development of critical care in England.

The paper offers a view of the development of critical care from the position of nursing. The nursing contribution is not fully acknowledged in the historical and professional literature. This paper offers an alternative history of the development of intensive care (ICU), which takes account of the nursing profession's contribution, rather than the commonly held view that ICU developed predominately as a result of new and innovative technology. The technology was not new but rather it was transferred, usually from the operating theatre, and applied to new conditions. There were many contributing factors that shaped the development of intensive care. One was the grouping together of sick patients so that they could be cared for by skilled nurses who 'watched over' them, by providing detailed observation. This paper outlines the development of intensive care in England from 1952 to the new millennium. It begins with an analysis of the changing definitions reflected in policy and professional documents before moving on to examine the factors that influenced its development and concludes with a discussion of the nursing contribution and future direction.

Nurse-led discharge to the ward from high dependency: a service improvement project.

Nurse-led discharge from the High Dependency Unit (HDU) was introduced in 2002 with the aim of improving access to level 2 beds (beds offering higher level of support and observation; ). The project has yet to be formally evaluated but there have been perceived benefits for both patients and staff.

Nurse led weaning from ventilatory and respiratory support.

Weaning from mechanical ventilation is challenging and requires expert knowledge and skill. Weaning can be defined as the process of assisting patients to breathe spontaneously without mechanical ventilatory support [Am. J. Crit. Care 7 (1998) 1491. Weaning from mechanical ventilation is not about the method used but more about how that method is employed [Crit. Care Med. 27 (1999) 2331]. A review of the literature revealed that there was no one method of weaning that was superior, furthermore evidence suggests that the use of a protocol was more effective in reducing the duration of weaning [Dimensions Crit. Care Nurs. 2 (1991) 398; Respir. Care Clin. North Am. 2 (1996) 105; AACN Clin. Issues Crit. Care 7 (1996) 550; Crit. Care Med. 25 (1997) 567; Arch. Surg. 133 (1998) 483; Chest 118 (2000) 459]. A retrospective audit of all patients who were ventilated for 7 or more days in one intensive care over a 1-year period, revealed 94 (of 500) patients were ventilated for an average of 16.8 days. There were no weaning guidelines or protocols in place at this time and weaning from mechanical ventilation was inconsistent and uncoordinated. A process mapping exercise revealed there was a delay in initiating the decision to wean of 96 h. Weaning protocols were put in place and nurse led weaning was initiated and supported by the nurse consultant. Monthly statistics were collated and this revealed the average ventilator time had reduced. Protocol led weaning has been effective in reducing the duration of ventilation. Problems still occur in initiating the decision to wean early. An audit of patient notes has revealed many reasons for this. These reasons include, over sedation, the use of morphine and midazolam, particularly in the elderly and those with renal impairment, is delaying weaning. Other reasons include, delay in tracheostomy placement. Staff are not initiating weaning guidelines early this may be due to lack of knowledge, lack of support or failure of the guidelines. Mechanisms are in place to support nurses at the bedside.

A multidisciplinary follow-up clinic after patients' discharge from ITU.

Follow-up clinics following discharge from intensive care are not a new phenomenon - Whiston Hospital in Liverpool has been running a clinic since 1990. Its pioneering work has set a precedent and has inspired Nottingham City Hospital to set up its own clinic. The Department of Health (2000) recommended that all NHS trusts 'review the provision of follow-up services and ensure there is appropriate provision for those patients who will benefit'. Nottingham City Hospital set up a multidisciplinary follow-up clinic without funding, with great success, over a year ago. This service has been extremely valuable to patients and their carers and has helped staff understand the needs of patients once they have left intensive care. This article will describe the clinic's work and case studies are utilized in order to illustrate key points.

A study exploring factors which influence the decision to commence nurse-led weaning.

Nurse-led weaning can improve patient outcome. Exploration of the factors that influence the commencement of weaning. Themes of decision-making, pathophysiological and multidisciplinary team factors emerged. Experience was a key factor in the decision to wean. The use of protocol-led weaning may not be useful in the decision to wean.