"What matters to you" on the day of surgery: Protocol for a mixed methods study.

BACKGROUND: The anticipation of anesthesia and surgery is the source of fear and anxiety in millions of patients worldwide. Although patients' fear and anxiety are recognized, more knowledge is needed to address patient responses and needs. Understanding the needs of the patients are important, and asking patients directly is the first step towards addressing these needs. This again might help reducing medications such as anesthetics and postoperative pain relief. The aim of this study protocol is to describe how we will investigate what matters to patients on the day of surgery, as well as their degree-of-worry and surgical fear. METHODS: Using a convergent mixed methods design with equal weighting of the qualitative and quantitative data strand we take advantage of the international "What Matters To You" Day on June 6, 2024 to conduct a flash mob study. We will approach perioperative departments around Denmark to participate and eligible patients arriving to the perioperative department for surgery will be invited to participate. Consenting patients are asked to complete a survey in three parts regarding (1) what matters to you, (2) degree-of-worry, and (3) surgical fear. We will use qualitative analysis for the first part and descriptive statistics for second and third parts. The data strands will be analyzed separately followed by integrated analysis and joint displays.

Nurses' and physicians' approaches to delirium management in the intensive care unit: A focus group investigation.

BACKGROUND: Delirium in the intensive care unit (ICU) is common, but reliable evidence-based recommendations are still limited. OBJECTIVES: The aim of our study was to explore nurses' and physicians' experiences and approaches to ICU delirium management. METHOD: Our study had a qualitative multicentre design using interdisciplinary focus groups and framework analysis. Participants were strategically selected to include nurses and physicians with experience in delirium management at five ICUs in four out of five regions in Denmark. RESULTS: We conducted eight focus group interviews with 24 nurses and 15 physicians; median ICU experience was 9 years (range 1-35). The main issues identified were (1) the decision to treat or not to treat ICU delirium based on delirium phenotype, (2) the decision to act based on experience or evidence, and (3) the decision to intervene using nursing care or medications. ICU delirium was treated with pharmacological interventions in patients with signs of agitation, hallucinations, and sleep deprivation. The first choice of agent was haloperidol or olanzapine. Agitated and combative patients received benzodiazepines, propofol, or dexmedetomidine. Calm delirious patients were managed with non-pharmacological solutions. Physicians recommended pro re nata (PRN) orders to prevent over medication, whereas nurses opposed PRN orders with the fear that it would increase their responsibilities. CONCLUSION: Our study described an algorithm of contemporary delirium management in Danish ICUs based on qualitative inquiry. When evidence-based solutions are unclear, nurses and physicians rely on personal experience, collective experience, and best available evidence to determine which patients to treat and what methods to use to treat ICU delirium. Delirium management still needs clear objectives and guidelines with evidence-based recommendations for first-line treatment and subsequent treatment options.

Fluctuations in sedation levels may contribute to delirium in ICU patients.

BACKGROUND: Delirium in patients admitted to the intensive care unit (ICU) is a serious complication potentially increasing morbidity and mortality. The aim of this study was to investigate the impact of fluctuating sedation levels on the incidence of delirium in ICU. METHODS: A prospective cohort study of adult patients at three multidisciplinary ICUs. The Richmond Agitation and Sedation Scale (RASS) and the Confusion Assessment Method for the ICU were used at least twice a day. RESULTS: Delirium was detected at least once in 65% of the patients (n = 640). Delirious patients were significantly older, more critically ill, more often intubated, had longer ICU stays, and had higher ICU mortality than non-delirious patients. The median duration of delirium was 3 days (interquartile range: 1;10), and RASS was less than or equal to 0 (alert and calm) 91% of the time. The odds ratio (OR) for development of delirium if RASS changed more than two levels was 5.19 when adjusted for gender, age, severity of illness, and ICU site and setting. Continuous infusion of midazolam was associated with a decrease in delirium incidence (OR: 0.38; P = 0.002). CONCLUSIONS: Fluctuations in sedation levels may contribute to development of delirium in ICU patients. The risk of developing delirium might be reduced by maintaining a stable sedation level or by non-sedation.

The effect of person-centred communication on parental stress in a NICU: a randomized clinical trial.

AIM: To investigate the effect of the Guided Family-Centred Care intervention, developed by the lead author, on parental stress in a neonatal intensive care unit (NICU). METHODS: Parents (n = 134) of infants born ≤34 weeks gestational age were randomly assigned to a standard care group (n = 60) or intervention group (n = 74) between April 2011 and August 2012. Guided Family-Centred Care components used were as follows: scheduled nurse-parent dialogues, semi-structured reflection sheets and person-centred communication. Parental stress was assessed at discharge using parent-reported outcomes on the Nurse Parent Support Tool and the Parental Stressor Scale: Neonatal Intensive Care Unit. RESULTS: The total stress scores reported by parents did not vary significantly between the intervention and standard groups, with a mean (SD) of 2.70 (0.67) versus 2.84 (0.71), respectively. However, the confidence interval included the prespecified clinical significance level. Subscale and Nurse Parent Support Tool scores did not differ between the groups. Overall, mothers reported more stress than fathers (p < 0.001). CONCLUSION: Our study was unable to demonstrate the effect of person-centred communication using the Guided Family-Centred Care intervention. It may be necessary to replicate the design to address the risk of contamination and add instruments sensitive to human interaction.

Comparison of pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a protocol for a systematic review incorporating network meta-analyses.

BACKGROUND: Delirium is characterized by acute changes in mental status including inattention, disorganized thinking, and altered level of consciousness, and is highly prevalent in critically ill adults. Delirium has adverse consequences for both patients and the healthcare system; however, at this time, no effective treatment exists. The identification of effective prevention strategies is therefore a clinical and research imperative. An important limitation of previous reviews of delirium prevention is that interventions were considered in isolation and only direct evidence was used. Our systematic review will synthesize all existing data using network meta-analysis, a powerful statistical approach that enables synthesis of both direct and indirect evidence. METHODS: We will search Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science from 1980 to March 2016. We will search the PROSPERO registry for protocols and the Cochrane Library for published systematic reviews. We will examine reference lists of pertinent reviews and search grey literature and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We will include randomized and quasi-randomized trials of critically ill adults evaluating any pharmacological, non-pharmacological, or multi-component intervention for delirium prevention, administered in or prior to (i.e., peri-operatively) transfer to the ICU. Two authors will independently screen search results and extract data from eligible studies. Risk of bias assessments will be completed on all included studies. To inform our network meta-analysis, we will first conduct conventional pair-wise meta-analyses for primary and secondary outcomes using random-effects models. We will generate our network meta-analysis using a Bayesian framework, assuming a common heterogeneity parameter across all comparisons, and accounting for correlations in multi-arm studies. We will perform analyses using WinBUGS software. DISCUSSION: This systematic review will address the existing knowledge gap regarding best practices for delirium prevention in critically ill adults by synthesizing evidence from trials of pharmacological, non-pharmacological, and multi-component interventions administered in or prior to transfer to the ICU. Use of network meta-analysis will clarify which delirium prevention strategies are most effective in improving clinical outcomes while causing least harm. The network meta-analysis is a novel approach and will provide knowledge users and decision makers with comparisons of multiple interventions of delirium prevention strategies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016036313.

Impact of follow-up consultations for ICU survivors on post-ICU syndrome: a systematic review and meta-analysis.

PURPOSE: To evaluate the impact of routine follow-up consultations versus standard of care for intensive care unit (ICU) survivors. METHODS: Systematic literature review from five databases (Cochrane CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL), reference lists, citation tracking, and ongoing/unpublished trials. Randomized controlled trials investigating post-ICU consultations in adults with outcomes such as quality of life (QOL), anxiety, depression, posttraumatic stress disorder (PTSD), physical ability, cognitive function, and return to work were included. Two reviewers extracted data and assessed quality independently. The mean differences, risk ratios, and 95 % confidence intervals were calculated depending on outcome measures. RESULTS: From 1544 citations, five trials were included (855 patients). The overall risk of bias was low in two trials, unclear in two trials, and high in one trial. The overall quality of evidence was low. The trials assessed follow-up interventions defined as consultations informing survivors about their ICU stay. One trial found no effect on QOL. Pooling data from two trials (n = 374) showed a protective effect on risk of new onset PTSD at 3-6 months after ICU (risk ratio 0.49, 95 % CI 0.26-0.95). There was no effect on other outcomes. CONCLUSIONS: The evidence indicates that follow-up consultations might reduce symptoms of PTSD at 3-6 months after ICU discharge in ICU survivors, but without affecting QOL and other outcomes investigated. This review highlights that planning of future RCTs should aim to standardize interventions and outcome measures to allow for comparisons across studies.

Rehabilitation activities, out-patient visits and employment in patients and partners the first year after ICU: a descriptive study.

OBJECTIVES: To describe the influence of critical illness on patients and their partners in relation to rehabilitation, healthcare consumption and employment during the first year after Intensive Care Unit discharge. DESIGN: Longitudinal, observational and descriptive. SETTING: Five Danish Intensive Care Units. METHODS: Data were collected from hospital charts, population registers and interviews with 18 patients and their partners at 3 and 12 months after intensive care discharge. Descriptive statistical analysis was performed. RESULTS: Post-discharge inpatient rehabilitation was median (range) 52 (15-174) days (n=10). Community-based training was 12 (3-34) weeks (n=15). Neuropsychological rehabilitation following brain damage was 13-20 weeks (n=3). Number of out-patient visits 1 year before and 1 year after were mean 3 versus 8, and General Practitioner visits were 12 versus 18. Three patients resumed work at pre-hospitalisation employment rates after 12 months. After the patients' stay in intensive care, partners' mean full-time sick leave was 17 (range 0-124) days and 21 (range 0-106) days part time. Partners often had long commutes. CONCLUSION: Most patients had comprehensive recovery needs requiring months of rehabilitation. Some partners needed extensive sick leave. The study reveals the human cost of critical illness and intensive care for patients and partners in the Danish welfare system.

Struggling for independence: a grounded theory study on convalescence of ICU survivors 12 months post ICU discharge.

OBJECTIVES: To explore and explain the challenges, concerns, and coping modalities in ICU-survivors living with a partner or spouse during the first 12 months post ICU discharge. DESIGN: Qualitative, longitudinal grounded theory study. SETTINGS: Five ICUs in Denmark, four general, one neurosurgical. METHODS: Thirty-five interviews with patients and their partners at three and 12 months post ICU discharge plus two group interviews with patients only and two with partners only. FINDINGS: The ICU survivors struggled for independence and focussed chiefly on 'recovering physical strength', 'regaining functional capacity', and 'resuming domestic roles'. The first year of recovery evolved in three phases characterised by training, perseverance and continued hope for recovery. The ICU survivors did not seem to worry about traumatic experiences. Rather, their focus was on a wide range of other aspects of getting well. CONCLUSION: The study offers new insight into post-ICU convalescence emphasising patients' motivation for training to recover. The findings may contribute to defining the best supportive measures and timing of rehabilitation interventions in ICU and post ICU that may help ICU-survivors in their struggle for independence throughout recovery.

Effects of salmeterol on mucosal inflammation in asthma: a placebo-controlled study.

Although the anti-inflammatory effects of inhaled corticosteroids in the treatment of asthma are established, the effects of long-acting beta2-adrenergic receptor agonists on inflammation are the subject of debate. The aim of the present study was to determine the effect of salmeterol on the numbers of inflammatory cells in biopsy samples of distinct immunophenotype and those expressing the genes for interleukin-4 and -5, regulatory cytokines particularly relevant to asthma. Twenty patients (aged 18-55 yrs) with mild stable asthma were randomised in a three-way crossover study to 6 weeks of treatment with: 1) salmeterol (50 microg b.d.; SM50); 2) fluticasone propionate (250 microg b.d.; FP250), or 3) placebo. Compared with placebo, SM50 significantly reduced the numbers of neutrophils in bronchial biopsy samples and the concentrations of myeloperoxidase and soluble E-selectin in serum, each of which reflect neutrophil involvement. Compared with FP250, SM50 reduced neutrophil number and human neutrophil lipocalin level in bronchial lavage fluid and intercellular adhesion molecule-1 level in bronchoalveolar lavage fluid. Compared with placebo, FP250 significantly reduced the numbers of (CD3+) T-lymphocytes, (CD4+) T-helper cells, (CD45RO+) activated T-helper cells and eosinophils in the biopsy samples; it also reduced the percentage of eosinophils and soluble intercellular adhesion molecule-1 in serum. The percentage of symptom-free days and nights and airways hyperresponsiveness improved significantly after SM50 compared to both placebo and FP250. In conclusion, a novel antineutrophilic effect of the inhaled long-acting beta2-adrenergic receptor agonist, salmeterol, in mild asthma is reported.