Safety, feasibility, and impact on the gut microbiome of kefir administration in critically ill adults.

BACKGROUND: Dysbiosis of the gut microbiome is frequent in the intensive care unit (ICU), potentially leading to a heightened risk of nosocomial infections. Enhancing the gut microbiome has been proposed as a strategic approach to mitigate potential adverse outcomes. While prior research on select probiotic supplements has not successfully shown to improve gut microbial diversity, fermented foods offer a promising alternative. In this open-label phase I safety and feasibility study, we examined the safety and feasibility of kefir as an initial step towards utilizing fermented foods to mitigate gut dysbiosis in critically ill patients. METHODS: We administered kefir in escalating doses (60 mL, followed by 120 mL after 12 h, then 240 mL daily) to 54 critically ill patients with an intact gastrointestinal tract. To evaluate kefir's safety, we monitored for gastrointestinal symptoms. Feasibility was determined by whether patients received a minimum of 75% of their assigned kefir doses. To assess changes in the gut microbiome composition following kefir administration, we collected two stool samples from 13 patients: one within 72 h of admission to the ICU and another at least 72 h after the first stool sample. RESULTS: After administering kefir, none of the 54 critically ill patients exhibited signs of kefir-related bacteremia. No side effects like bloating, vomiting, or aspiration were noted, except for diarrhea in two patients concurrently on laxatives. Out of the 393 kefir doses prescribed for all participants, 359 (91%) were successfully administered. We were able to collect an initial stool sample from 29 (54%) patients and a follow-up sample from 13 (24%) patients. Analysis of the 26 paired samples revealed no increase in gut microbial α-diversity between the two timepoints. However, there was a significant improvement in the Gut Microbiome Wellness Index (GMWI) by the second timepoint (P = 0.034, one-sided Wilcoxon signed-rank test); this finding supports our hypothesis that kefir administration can improve gut health in critically ill patients. Additionally, the known microbial species in kefir were found to exhibit varying levels of engraftment in patients' guts. CONCLUSIONS: Providing kefir to critically ill individuals is safe and feasible. Our findings warrant a larger evaluation of kefir's safety, tolerability, and impact on gut microbiome dysbiosis in patients admitted to the ICU. TRIAL REGISTRATION: NCT05416814; trial registered on June 13, 2022.

Psychiatry's role in the prevention of post-intensive care mental health impairment: stakeholder survey.

BACKGROUND: Many critical illness survivors experience new or worsening mental health impairments. Psychiatry consultation services can provide a critical role in identifying, addressing, and preventing mental health challenges during and after admission to the acute medical care setting. However, psychiatry involvement in the ICU setting is lower than in other hospital settings and the conventional process in many hospitals requires other care providers to request consultation by psychiatry. Despite these differences, no studies have sought ICU provider perspectives on psychiatry consultation's current and desired role. We aimed to obtain stakeholder feedback on psychiatry's current and desired roles in the ICU, and potential benefits and drawbacks of increasing psychiatry's presence. METHODS: A web-based survey obtained perspectives from 373 critical care physicians and advance practice providers, bedside nurses, physical and occupational therapists, pharmacists, and consultation-liaison psychiatry physicians and advance practice providers at a tertiary care center using multiple choice and open-ended questions. Descriptive information and content analysis of qualitative data provided information on stakeholder perspectives. RESULTS: Psychiatry's primary current role was seen as assistance with management of mental health issues (38%) and suicide risk assessments (23%). 46% wished for psychiatry's increased involvement in the ICU. Perceived benefits of increased psychiatry presence in the ICU included early psychological support in parallel with medical care, identification of psychiatric factors impacting treatment, and facilitation of family understanding of the patient's mental state/delirium. An additional perceived benefit included reduction in provider burnout through processing difficult situations and decreasing family psychological distress. However, one concern included potential conflict among providers regarding treatment. CONCLUSIONS: Those who work closely with the critically ill patients think that increased psychological support in the ICU would be beneficial. By contrast, psychiatry's current involvement is seen to be limited, perhaps driven by varying perceptions of what psychiatry's role is or should be.

A pilot study of trained ICU doulas providing early psychological support to critically ill patients.

BACKGROUND: Over a third of critical illness survivors suffer from mental health problems following hospitalization. Memories of delusional experiences are a major risk factor. In this project, ICU doulas delivered a unique positive suggestion intervention targeting the vulnerable time period during critical illness when these memories are formed. METHODS: Adult critically ill patients were recruited for this single-arm, prospective pilot study. These ICU patients received a positive suggestion intervention daily during their ICU stay in parallel with their medical treatment. The intervention was designed to be delivered over a minimum of two sessions. Feasibility was defined as intervention delivery on ≥ 70% of ICU days after patient enrollment. As a secondary analysis, psychometric questionnaires were compared to those of a historic control cohort of patients receiving standard care in the ICU using adjusted linear regression models. RESULTS: Of the 97 patients who received the intervention and were alive at the end of their ICU course, 54 were excluded from analyses mostly for having received only one session because of a short ICU length of stay of < 2 days, transitioning to comfort care or not wanting to answer the study questionnaires. Forty-three patients who completed 2 or more sessions of the positive therapeutic suggestion intervention provided by two trained ICU doulas received it for a median of 4 days (IQR 3, 5), with each session lasting for a median of 20 min (IQR 14, 25). The intervention was delivered on 71% of days, meeting our pre-determined feasibility goal. Compared to historical controls (N = 299), patients receiving the intervention had higher severity of illness and longer length of stay. When adjusted for baseline differences, patients both with and without mechanical ventilation who received the intervention scored lower on the Hospital Anxiety and Depression Scale (HADS)-Depression subscale. The intervention was also associated with reduced HADS-Anxiety subscale among ventilated patients. CONCLUSIONS: Positive therapeutic suggestion delivered by ICU doulas is feasible in the ICU setting. A randomized trial is warranted to better delineate the role that positive suggestion and ICU doulas may play in ongoing interprofessional efforts to humanize critical care medicine. The study was registered on clinicaltrials.gov (NCT03736954) on 03/14/2018 prior to the first patient enrollment https://clinicaltrials.gov/ct2/show/NCT03736954?cond=ICU+Doulas+Providing+Psychological+Support&draw=2&rank=1 .

Early Psychological Therapy in Critical Illness.

Survivors of critical illness often experience long-lasting impairments in mental, cognitive, and physical functioning. Acute stress reactions and delusional memories appear to play an important role in psychological morbidity following critical illness, and few interventions exist to address these symptoms. This review elucidates acute psychological stressors experienced by the critically ill. The effects of psychological stress and state of mind on disease are discussed using examples from the non-intensive care unit (ICU) literature, including a review of placebo and nocebo effects. After reviewing the effect of the mind on both psychological and physiological outcomes, we then focus on the role of memories-including their malleable nature and the consequences of false memories. Memory may play a role in the genesis of subsequent psychological trauma. Traumatic memories may begin forming even before the patient arrives in the ICU and during their state of unconsciousness in the ICU. Hence, practical interventions for redirecting patients' thoughts, such as positive suggestion techniques and actively involving patients in the treatment process as early as possible, are worthy of further investigation.

Cardiac arrest in a 21-year-old man after ingestion of 1,3-DMAA-containing workout supplement.

Dietary supplements containing 1,3-dimethylamylamine (DMAA) have been determined to be illegal by the Food and Drug Administration (FDA); although banned, the products are still widely available for purchase. Adverse effects reported include cardiac arrest, hemorrhagic stroke, and death. Nonetheless, such products remain popular among young people because of advertised claims of exercise performance enhancement and fat burning. We describe a case of a young man who took such a supplement and suffered a cardiac arrest. Notably, the product consumed was not on the FDA list of substances containing DMAA. This case highlights the importance for clinicians to be aware of the potential harm of the DMAA-containing products by maintaining a high index of suspicion in otherwise healthy individuals presenting with cardiac arrest. It is of particular importance to sports medicine physicians who are most involved in education and counseling of patients potentially at risk of taking such products.

Effect of prolonged therapeutic hypothermia on intracranial pressure, organ function, and hospital outcomes among patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND: Global cerebral edema (GCE) with subsequent refractory intracranial hypertension complicates some cases of aneurysmal subarachnoid hemorrhage (aSAH), and typically is associated with poorer outcome. Treatment options for refractory intracranial pressure (ICP) cases are limited to decompressive hemicraniectomy (DHC) and targeted temperature management (TTM) with induced hypothermia (32-34 °C). No outcomes comparison between patients treated with either or both forms of refractory ICP therapy exists, and data on the effect of prolonged hypothermia on ICP and organ function among patients with aSAH are limited. METHODS: This is a retrospective study of aSAH patients who underwent DHC and/or prolonged hypothermia (greater than 48 h) for refractory ICP (i.e., ICP >20 mmHg after osmotherapy) in the intensive care unit of a single, tertiary-care academic center. RESULTS: Nineteen individuals with aSAH underwent TTM with or without DHC; sixteen patients underwent DHC alone. The patients in TTM group were younger (median age 44 years) than the DHC without TTM population (median age 60 years). TTM was started on median day 2 with a median duration of 7 days. There were no significant group differences in survival to discharge (59 % vs. 69 %) or in the mean modified Rankin score on follow-up (3.6 vs. 3.7), despite the TTM group having longer hospital length of stay (24 vs. 19 days, p = 0.03), longer duration of mechanical ventilation (20 vs. 9 days, p = 0.04), a higher cumulative fluid balance (12.8 vs. 5.1 L, p = 0.01), and higher APACHEII scores. The median maximal ICP decreased from 23.5 to 21 mmHg within 24 h of hypothermia initiation. There were no significant differences in other markers of end-organ function (respiratory, hematologic, renal, liver, and cardiac), infection rate, or adverse events between groups. CONCLUSIONS: Use of prolonged TTM among aSAH patients with GCE and refractory ICP elevations is associated with a longer duration of mechanical ventilation but is not different in terms of neurological outcomes measured by modified Rankin score or organ function outcomes compared to patients who received DHC alone.

Communication in the ICU: An Unintended Nocebo Effect?

To identify medical phrases utilized by the critical care team that may have an unintended impact on the critically ill patient, we administered an anonymous survey to multi-professional critical care team members. We elicited examples of imprecise language that may have a negative emotional impact on the critically ill. Of the 1600 providers surveyed, 265 offered 1379 examples (912 unique) which were clustered into 5 categories. Medical jargon (eg, "riding the vent") was most prevalent (n = 549). There were 217 negative suggestions (eg, "you will feel a stick and a burn"). Hyperboles (eg, "black cloud") were common (n = 198) while homonyms (ie "he fibbed") accounted for 150 examples. Phrases such as "code brown in there" were categorized as metonyms (n = 144). 121 metaphors/similes (eg, "rearranging deck chairs on the Titanic") were provided. Phrases that have the potential to negatively impact critically ill patient perceptions are commonplace in critical care practice. Whether these everyday communication habits lead to an unintended nocebo effect on mental health outcomes of the critically ill deserves further study.

The human gut microbiome in critical illness: disruptions, consequences, and therapeutic frontiers.

With approximately 39 trillion cells and over 20 million genes, the human gut microbiome plays an integral role in both health and disease. Modern living has brought a widespread use of processed food and beverages, antimicrobial and immunomodulatory drugs, and invasive procedures, all of which profoundly disrupt the delicate homeostasis between the host and its microbiome. Of particular interest is the human gut microbiome, which is progressively being recognized as an important contributing factor in many aspects of critical illness, from predisposition to recovery. Herein, we describe the current understanding of the adverse impacts of standard intensive care interventions on the human gut microbiome and delve into how these microbial alterations can influence patient outcomes. Additionally, we explore the potential association between the gut microbiome and post-intensive care syndrome, shedding light on a previously underappreciated avenue that may enhance patient recuperation following critical illness. There is an impending need for future epidemiological studies to encompass detailed phenotypic analyses of gut microbiome perturbations. Interventions aimed at restoring the gut microbiome represent a promising therapeutic frontier in the quest to prevent and treat critical illnesses.

Gut Microbiome Wellness Index 2 enhances health status prediction from gut microbiome taxonomic profiles.

Recent advancements in translational gut microbiome research have revealed its crucial role in shaping predictive healthcare applications. Herein, we introduce the Gut Microbiome Wellness Index 2 (GMWI2), an enhanced version of our original GMWI prototype, designed as a standardized disease-agnostic health status indicator based on gut microbiome taxonomic profiles. Our analysis involves pooling existing 8069 stool shotgun metagenomes from 54 published studies across a global demographic landscape (spanning 26 countries and six continents) to identify gut taxonomic signals linked to disease presence or absence. GMWI2 achieves a cross-validation balanced accuracy of 80% in distinguishing healthy (no disease) from non-healthy (diseased) individuals and surpasses 90% accuracy for samples with higher confidence (i.e., outside the "reject option"). This performance exceeds that of the original GMWI model and traditional species-level α-diversity indices, indicating a more robust gut microbiome signature for differentiating between healthy and non-healthy phenotypes across multiple diseases. When assessed through inter-study validation and external validation cohorts, GMWI2 maintains an average accuracy of nearly 75%. Furthermore, by reevaluating previously published datasets, GMWI2 offers new insights into the effects of diet, antibiotic exposure, and fecal microbiota transplantation on gut health. Available as an open-source command-line tool, GMWI2 represents a timely, pivotal resource for evaluating health using an individual's unique gut microbial composition.

The influence of prehospital systemic corticosteroid use on development of acute respiratory distress syndrome and hospital outcomes.

OBJECTIVE: The role of systemic corticosteroids in pathophysiology and treatment of acute respiratory distress syndrome is controversial. Use of prehospital systemic corticosteroid therapy may prevent the development of acute respiratory distress syndrome and improve hospital outcomes. DESIGN: This is a preplanned retrospective subgroup analysis of the prospectively identified cohort from a trial by the U.S. Critical Illness and Injury Trials Group designed to validate the Lung Injury Prediction Score. SETTING: Twenty-two acute care hospitals. PATIENTS: : Five thousand eighty-nine patients with at least one risk factor for acute respiratory distress syndrome at the time of hospitalization. INTERVENTION: Propensity-based analysis of previously recorded data. MEASUREMENTS AND MAIN RESULTS: Three hundred sixty-four patients were on systemic corticosteroids. Prevalence of acute respiratory distress syndrome was 7.7% and 6.9% (odds ratio, 1.1 [95% CI, 0.8-1.7]; p = 0.54) for patients on systemic corticosteroid and not on systemic corticosteroids, respectively. A propensity for being on systemic corticosteroids was derived through logistic regression by using all available covariates. Subsequently, 354 patients (97%) on systemic corticosteroids were matched to 1,093 not on systemic corticosteroids by their propensity score for a total of 1,447 patients in the matched set. Adjusted risk for acute respiratory distress syndrome (odds ratio, 0.96 [95% CI, 0.54-1.38]), invasive ventilation (odds ratio, 0.84 [95% CI, 0.62-1.12]), and in-hospital mortality (odds ratio, 0.97 [95% CI, 0.63-1.49]) was then calculated from the propensity-matched sample using conditional logistic regression model. No significant associations were present. CONCLUSIONS: Prehospital use of systemic corticosteroids neither decreased the development of acute respiratory distress syndrome among patients hospitalized with at one least risk factor, nor affected the need for mechanical ventilation or hospital mortality.

Whole Blood Reactivity to Viral and Bacterial Pathogens after Non-Emergent Cardiac Surgery during the Acute and Convalescence Periods Demonstrates a Distinctive Profile of Cytokines Production Compared to the Preoperative Baseline in Cohort of 108 Patients, Suggesting Immunological Reprogramming during the 28 Days Traditionally Recognized as the Post-Surgical Recovery Period.

The release of danger signals from tissues in response to trauma during cardiac surgery creates conditions to reprogram the immune system to subsequent challenges posed by pathogens in the postoperative period. To demonstrate this, we tested immunoreactivity before surgery as the baseline (tbaseline), followed by subsequent challenges during the acute phase (t24h), convalescence (t7d), and long-term recovery (t3m). For 108 patients undergoing elective heart surgery, whole blood was stimulated with lipopolysaccharide (LPS), Influenza A virus subtype N2 (H3N2), or the Flublok™ vaccine to represent common pathogenic challenges. Leukocytosis, platelet count, and serum C-reactive protein (CRP) were used to measure non-specific inflammation. Cytokines were measured after 18 h of stimulation to reflect activation of the various cell types (activated neutrophils-IL-8; activated T cells-IL-2, IFNγ, activated monocyte (MO)-TNFα, IL-6, and deactivated or atypically activated MO and/or T cells-M-CSF, IL-10). IL-2 and IL-10 were increased at t7d, while TNFα was suppressed at t24h when LPS was utilized. Interestingly, M-CSF and IL-6 production was elevated at seven days in response to all stimuli compared to baseline. While some non-specific markers of inflammation (white cell count, IL-6, and IL-8) returned to presurgical levels at t3m, CRP and platelet counts remained elevated. We showed that surgical stimulus reprograms leukocyte response to LPS with only partial restoration of non-specific markers of inflammation.

Determining Goal Concordant Care in the Intensive Care Unit Using Electronic Health Records.

BACKGROUND: Goal concordant care (GCC) is the alignment of care to patient values and preferences. GCC is a major outcome of communication with patients and families in serious/critical illness. Using the electronic health record (EHR) to study the provision of GCC would be pragmatic and cost-effective for research and quality improvement efforts. RESEARCH QUESTION: Do EHRs contain information to identify GCC? METHODS: This is a feasibility retrospective chart review performed by two independent reviewers. An existing framework containing four questions for identifying GCC was adopted. Two clinicians reviewed multi-disciplinary notes and extracted pertinent information. The primary outcomes were whether the four key questions for determining goal concordance could be answered using information in the EHR. The secondary outcome was the type of goals identified. Cohen's kappa was used to measure agreement between two reviewers. RESULTS: Patient care was considered goal concordant in 35 (85%) of 41 patients in a random sample comprising of 36 survivors and five who died in hospital. Inter-rater agreement on identifying data to determine GCC was excellent (Kappa 0.70). Patient goals were identified in 80% of charts reviewed. Note sources informative of patient preferences, included social work (39%), hospital progress notes (29%), palliative care (20%), and physical/occupational therapy (15%). "Returning home" and "getting better/ stronger" were among the most common patient goals captured in EHR. CONCLUSION: The EHR can be used to understand patient goals, but the information is scattered across the multi-disciplinary notes. Improving EHR and external validation will facilitate ascertainment of goal concordance as an important outcome measure.

Aloud real- time reading of intensive care unit diaries: A feasibility study.

OBJECTIVES: Memories of frightening/delusional intensive care unit experiences are a major risk factor for subsequent psychiatric morbidity of critical illness survivors; factual memories are protective. Systematically providing factual information during initial memory consolidation could mitigate the emotional character of the formed memories. We explored feasibility and obtained stakeholder feedback of a novel approach to intensive care unit diaries whereby entries were read aloud to the patients right after they were written to facilitate systematic real time orientation and formation of factual memories. RESEARCH METHODOLOGY: Prospective interventional pilot study involving reading diary entries aloud. We have also interviewed involved stakeholders for feedback and collected exploratory data on psychiatric symptoms from patients right after the intensive care stay. SETTING: Various intensive care units in a single academic center. MAIN OUTCOME MEASURES: Feasibility was defined as intervention delivery on ≥80% of days following patient recruitment. Content analysis was performed on stakeholder interview responses. Questionnaire data were compared for patients who received real-time reading to the historical cohort who did not. RESULTS: Overall, 57% (17 of 30) of patients achieved the set feasibility threshold. Following protocol adjustment, we achieved 86% feasibility in the last subset of patients. Patients reported the intervention as comforting and appreciated the reorientation aspect. Nurses overwhelmingly liked the idea; most common concern was not knowing what to write. Some therapists were unsure whether reading entries aloud might overwhelm the patients. There were no significant differences in psychiatric symptoms when compared to the historic cohort. CONCLUSION: We encountered several implementation obstacles; once these were addressed, we achieved set feasibility target for the last group of patients. Reading diary entries aloud was welcomed by stakeholders. Designing a trial to assess efficacy of the intervention on psychiatric outcomes appears warranted. IMPLICATIONS FOR CLINICAL PRACTICE: There is no recommendation to change current practice as benefits of the intervention are unproven.

Humanizing the Intensive Care Unit: Perspectives of Patients and Families on the Get to Know Me Board.

In this qualitative study, we explored perspectives of patients in the intensive care unit (ICU) and their families on the Get to Know Me board (GTKMB). Of the 46 patients approached, 38 consented to participate. Of the 66 family members approached, 60 consented to participate. Most patients (26, 89%) and family members (52, 99%) expressed that GTKMB was important in recognizing patient's humanity. Most patients (20, 68%) and families (39, 74%) said that it helped to build a better relationship with the provider team. 60% of patients and families commented that the GTKMB was used as a platform by providers to interact with them. Up to 45 (85%) of the family members supported specific contents of the GTKMB. In structured interviews (11 patients, 7 family members), participants additionally commented on ways providers used the GTKMB to communicate, support patient's personhood, and on caveats in interacting with GTKMB. Critically ill patients and families found the GTKMB helpful in preserving personhood of patient, fostering communication, and building relationships with clinicians.

Gut Microbiome Wellness Index 2 for Enhanced Health Status Prediction from Gut Microbiome Taxonomic Profiles.

Recent advancements in human gut microbiome research have revealed its crucial role in shaping innovative predictive healthcare applications. We introduce Gut Microbiome Wellness Index 2 (GMWI2), an advanced iteration of our original GMWI prototype, designed as a robust, disease-agnostic health status indicator based on gut microbiome taxonomic profiles. Our analysis involved pooling existing 8069 stool shotgun metagenome data across a global demographic landscape to effectively capture biological signals linking gut taxonomies to health. GMWI2 achieves a cross-validation balanced accuracy of 80% in distinguishing healthy (no disease) from non-healthy (diseased) individuals and surpasses 90% accuracy for samples with higher confidence (i.e., outside the "reject option"). The enhanced classification accuracy of GMWI2 outperforms both the original GMWI model and traditional species-level α-diversity indices, suggesting a more reliable tool for differentiating between healthy and non-healthy phenotypes using gut microbiome data. Furthermore, by reevaluating and reinterpreting previously published data, GMWI2 provides fresh insights into the established understanding of how diet, antibiotic exposure, and fecal microbiota transplantation influence gut health. Looking ahead, GMWI2 represents a timely pivotal tool for evaluating health based on an individual's unique gut microbial composition, paving the way for the early screening of adverse gut health shifts. GMWI2 is offered as an open-source command-line tool, ensuring it is both accessible to and adaptable for researchers interested in the translational applications of human gut microbiome science.

Feasibility of Extracting Meaningful Patient Centered Outcomes From the Electronic Health Record Following Critical Illness in the Elderly.

Background: Meaningful patient centered outcomes of critical illness such as functional status, cognition and mental health are studied using validated measurement tools that may often be impractical outside the research setting. The Electronic health record (EHR) contains a plethora of information pertaining to these domains. We sought to determine how feasible and reliable it is to assess meaningful patient centered outcomes from the EHR. Methods: Two independent investigators reviewed EHR of a random sample of ICU patients looking at documented assessments of trajectory of functional status, cognition, and mental health. Cohen's kappa was used to measure agreement between 2 reviewers. Post ICU health in these domains 12 month after admission was compared to pre- ICU health in the 12 months prior to assess qualitatively whether a patient's condition was "better," "unchanged" or "worse." Days alive and out of hospital/health care facility was a secondary outcome. Results: Thirty six of the 41 randomly selected patients (88%) survived critical illness. EHR contained sufficient information to determine the difference in health status before and after critical illness in most survivors (86%). Decline in functional status (36%), cognition (11%), and mental health (11%) following ICU admission was observed compared to premorbid baseline. Agreement between reviewers was excellent (kappa ranging from 0.966 to 1). Eighteen patients (44%) remained home after discharge from hospital and rehabilitation during the 12- month follow up. Conclusion: We demonstrated the feasibility and reliability of assessing the trajectory of changes in functional status, cognition, and selected mental health outcomes from EHR of critically ill patients. If validated in a larger, representative sample, these outcomes could be used alongside survival in quality improvement studies and pragmatic clinical trials.

System of Psychological Support Based on Positive Suggestions to the Critically Ill Using ICU Doulas.

Surviving critical illness often creates a lasting psychological impact, including depression, anxiety, and post-traumatic stress. Memories of frightening and delusional experiences are the largest potentially modifiable risk factor, but currently, there is no proven intervention to improve these inciting factors. Psychological support based on positive suggestion is a psychotherapeutic approach that can be provided even to patients in altered cognitive states and is therefore a viable psychotherapy intervention throughout the ICU stay. Traditional ICU care team members have limited time and training to provide such psychological support to patients. Doulas are trained supportive companions who have been effectively used to provide patient advocacy and emotional support in other clinical settings and may address this need. Our aim was to train and implement a psychological support based on positive suggestion program for the critically ill using doulas, and measure acceptance of this intervention through stakeholder feedback. METHODS: Doula training included three objectives: an introduction to ICU practice structure and policies; education about fundamental aspects of critical care conditions and procedures; and didactic and hands-on learning experiences in effective use of psychological support based on positive suggestion in the critically ill. Doulas were evaluated at the end of their training and during subsequent clinical activities using competency-based assessments as well as through survey-based questions and interviews with key stakeholders. RESULTS: The ICU doulas performed psychological support based on positive suggestion on 43 critically ill patients in the ICU setting. Stakeholder feedback from nurses, patients, and patient families was positive. The majority (28/32) of surveyed bedside ICU nurses reported that the doulas' involvement was helpful for both patients and nurses alike. All interviewed family members offered positive comments about the ICU doula presence and of the 40 patients who recalled the intervention 37 found it comforting. CONCLUSIONS: Our program successfully trained two doulas to work effectively in the ICU setting performing patient-centered psychological support based on positive suggestion interventions. Their training improved their skill sets and was reported as beneficial by patients, families, and critical care nursing. This training program offers a proof of concept that could be applied in other medical centers, bringing doulas more commonly into the ICU practice to help humanize the experience for patients, families, and medical teams.

Feasibility of a Behavioral Intervention to Reduce Psychological Distress in Mechanically Ventilated Patients.

Many survivors of acute respiratory failure suffer from mood disorders following discharge from the hospital. We investigated the feasibility of intensivists delivering psychological support based on positive suggestion (PSBPS) to 20 intubated patients to reduce their psychological distress. Thirteen patients completed follow-up surveys. Of those, 9 remembered the intensive care unit physician talking to them, and 7 described it as comforting. Five patients (38%) met criteria for anxiety, depression, and acute stress. In comparison to historical controls, intervention may be associated with lower estimated odds of anxiety. PSBPS can be performed with patients in parallel with medical treatment to potentially reduce psychological morbidity and to humanize critical care. A larger randomized study is warranted to assess the efficacy of PSBPS.