Effect of a Standardized Family Participation Program in the ICU: A Multicenter Stepped-Wedge Cluster Randomized Controlled Trial.

OBJECTIVES: To determine the effect of a standardized program for family participation in essential care activities in the ICU on symptoms of anxiety, depression, posttraumatic stress and satisfaction among relatives, and perceptions and experiences of ICU healthcare providers (HCPs). DESIGN: Multicenter stepped-wedge cluster randomized controlled trial. SETTING: Seven adult ICUs, one university, and six general teaching hospitals. PARTICIPANTS: Three hundred six relatives and 235 ICU HCPs. INTERVENTIONS: A standardized program to facilitate family participation inpatient communication, amusement/distraction, comfort, personal care, breathing, mobilization, and nutrition. MEASUREMENTS AND MAIN RESULTS: Data were collected through surveys among relatives and ICU HCPs. There were no significant differences in symptoms of anxiety in relatives in the intervention period compared with the control period (median Hospital Anxiety and Depression Scale [HADS] 5 [interquartile range (IQR) 2-10] vs 6 [IQR 3-9]; median ratio [MR] 0.72; 95% CI, 0.46-1.13; p = 0.15), depression (median HADS 4 [IQR 2-6] vs 3 [IQR 1-6]; MR 0.85; 95% CI, 0.55-1.32; p = 0.47) or posttraumatic stress (median Impact of Event Scale-Revised score 0.45 [IQR 0.27-0.82] vs 0.41 [IQR 0.14-1]; MR 0.94; 95% CI, 0.78-1.14; p = 0.54). Reported satisfaction was slightly lower in the intervention period (mean 8.90 [ sd 1.10] vs mean 9.06 [ sd 1.10], difference -0.60; 95% CI, -1.07 to -0.12; p = 0.01). ICU HCPs perceived that more relatives knew how to participate: 47% in the intervention period versus 22% in the control period (odds ratio [OR] 3.15; 95% CI, 1.64-6.05; p < 0.01). They also reported relatives having sufficient knowledge (41% vs 16%; OR 3.56; 95% CI, 1.75-7.25; p < 0.01) and skills (44% vs 25%; OR 2.38; 95% CI, 1.22-4.63; p = 0.01) to apply family participation. CONCLUSIONS: Application of a standardized program to facilitate family participation did not change mental health symptoms in relatives of ICU patients 3 months after discharge. ICU HCPs reported increased clarity, knowledge, and skills among relatives and ICU HCPs.

Varying (preferred) levels of involvement in treatment decision-making in the intensive care unit before and during the COVID-19 pandemic: a mixed-methods study among relatives.

BACKGROUND: In the intensive care unit (ICU) relatives play a crucial role as surrogate decision-makers, since most patients cannot communicate due to their illness and treatment. Their level of involvement in decision-making can affect their psychological well-being. During the COVID-19 pandemic, relatives' involvement probably changed. We aim to investigate relatives' involvement in decision-making in the ICU before and during the pandemic and their experiences and preferences in this regard. METHODS: A mixed-methods study among relatives of ICU patients admitted to an ICU before or during the COVID-19 pandemic. Relatives in six ICUs completed a questionnaire (n = 329), including two items on decision-making. These were analysed using descriptive statistics and logistic regression analyses. Subsequently, relatives (n = 24) were interviewed about their experiences and preferences regarding decision-making. Thematic analysis was used for analysing the qualitative data. RESULTS: Nearly 55% of the relatives indicated they were at least occasionally asked to be involved in important treatment decisions and of these relatives 97.1% reported to have had enough time to discuss questions and concerns when important decisions were to be made. During the first COVID-19 wave relatives were significantly less likely to be involved in decision-making compared to relatives from pre-COVID-19. The interviews showed that involvement varied from being informed about an already made decision to deliberation about the best treatment option. Preferences for involvement also varied, with some relatives preferring no involvement due to a perceived lack of expertise and others preferring an active role as the patient's advocate. Discussing a patient's quality of life was appreciated by relatives, and according to relatives healthcare professionals also found this valuable. In some cases the preferred and actual involvement was in discordance, preferring either a larger or a smaller role. CONCLUSIONS: As treatment alignment with a patient's values and preferences and accordance between preferred and actual involvement in decision-making is very important, we suggest that the treatment decision-making process should start with discussions about a patient's quality of life, followed by tailoring the process to relatives' preferences as much as possible. Healthcare professionals should be aware of relatives' heterogeneous and possibly changing preferences regarding the decision-making process.

ERASE: a feasible early warning tool for elder abuse, developed for use in the Dutch emergency department.

BACKGROUND: Elder abuse is a worldwide problem with serious consequences for individuals and society. To effectively deal with elder abuse, a timely identification of signals as well as a systematic approach towards (suspected) elder abuse is necessary. This study aimed to develop and test the acceptability and appropriateness of ERASE (EldeR AbuSE) in the emergency department (ED) setting. ERASE is an early warning tool for elder abuse self-administered by the healthcare professional in patients ≥ 70 years. METHODS: A systematic literature review was previously conducted to identify potential available instruments on elder abuse for use in the ED. Furthermore, a field consultation in Dutch hospitals was performed to identify practice tools and potential questions on the recognition of elder abuse that were available in clinical practice. Based on this input, in three subsequent rounds the ERASE tool was developed. The ERASE tool was tested in a pilot feasibility study in healthcare professionals (n = 28) working in the ED in three Dutch hospitals. A semi-structured online questionnaire was used to determine acceptability and appropriateness of the ERASE tool. RESULTS: The systematic literature review revealed seven screening instruments developed for use in the hospital and/or ED setting. In total n = 32 (44%) hospitals responded to the field search. No suitable and validated instruments for the detection of elder abuse in the ED were identified. The ERASE tool was developed, with a gut feeling awareness question, that encompassed all forms of elder abuse as starting question. Subsequently six signalling questions were developed to collect information on observed signs and symptoms of elder abuse and neglect. The pilot study showed that the ERASE tool raised the recognition of healthcare professionals for elder abuse. The tool was evaluated acceptable and appropriate for use in the ED setting. CONCLUSIONS: ERASE as early warning tool is guided by an initial gut feeling awareness question and six signalling questions. The ERASE tool raised the recognition of healthcare professionals for elder abuse, and was feasible to use in the ED setting. The next step will be to investigate the reliability and validity of the ERASE early warning tool.

Support for relatives in the intensive care unit: lessons from a cross-sectional multicentre cohort study during the COVID-19 pandemic.

BACKGROUND: Support for relatives is highly important in the intensive care unit (ICU). During the first COVID-19 wave  support for relatives had to be changed considerably. The alternative support could have decreased the quality and sense of support. We aimed to evaluate how support for relatives in Dutch ICUs was organised during the first COVID-19 wave and how this was experienced by these relatives in comparison to relatives from pre-COVID-19 and the second wave. Additionally, we aimed to investigate which elements of support are associated with positive experiences. METHODS: We performed a cross-sectional multicentre cohort study in six Dutch ICUs in the Netherlands. Written questionnaires were distributed among relatives of ICU patients from pre-COVID-19, the first wave and the second wave. The questionnaire included questions on demographics, the organisation of support, and the experiences and satisfaction of relatives with the support. RESULTS: A total of 329 relatives completed the questionnaire (52% partner, 72% woman and 63% ICU stay of 11 days or longer). Support for relatives of ICU patients during the first COVID-19 wave differed significantly from pre-COVID-19 and the second wave. Differences were found in all categories of elements of support: who, when, how and what. Overall, relatives from the three time periods were very positive about the support. The only difference in satisfaction between the three time periods, was the higher proportion of relatives indicating that healthcare professionals had enough time for them during the first wave. Elements of support which were associated with many positive experiences and satisfaction were: fixed timeslot, receiving information (e.g. leaflets) on ≥ 2 topics, discussing > 5 topics with healthcare professionals, and being offered emotional support. CONCLUSIONS: Although, support for relatives in the ICU changed considerably during the COVID-19 pandemic, relatives were still positive about this support. The altered support gave insight into avenues for improvement for future comparable situations as well as for normal daily ICU practice: e.g. daily contact at a fixed timeslot, offering video calling between patients and relatives, and offering emotional support. ICUs should consider which elements need improvement in their practice.

Family participation in essential care activities in adult intensive care units: An integrative review of interventions and outcomes.

AIMS AND OBJECTIVES: To systematically review interventions and outcomes regarding family participation in essential care in adult intensive care units. BACKGROUND: Patients and relatives may benefit from family participation in essential care activities. DESIGN: An integrative literature review. METHODS: The following databases were systematically searched from inception to January 25, 2021: PubMed, CINAHL, EMBASE, MEDLINE, Cochrane, Web of Science and reference lists of included articles. Studies were included when reporting on family participation in essential care activities in intensive care including interventions and outcomes. Quality of the studies was assessed with the Kmet Standard Quality Assessment Criteria. Interventions were assessed, using the TIDieR framework. Data were extracted and synthesised narratively. RESULTS: A total of 6698 records were screened, and 322 full-text studies were assessed. Seven studies were included, describing an intervention to support family participation. Four studies had a pretest-posttest design, two were pilot feasibility studies and one was observational. The quality of the studies was poor to good, with Kmet-scores: 0.50-0.86 (possible score: 0-1, 1 being the highest). Five studies offered various essential care activities. One study provided sufficient intervention detail. Outcome measures among relatives varied from mental health symptoms to satisfaction, supportiveness, comfort level and experience. Two studies measured patient outcomes: delirium and pressure ulcers. Among ICU healthcare providers, perception, comfort level and experience were assessed. Since outcome measures varied, only narrative synthesis was possible. Family participation is associated with a reduction of anxiety and PTSD symptoms. CONCLUSION: Intervention descriptions of family participation in essential care activities are generally inadequate and do not allow comparison and replication. Participation of relatives was associated with a significant reduction in mental health symptoms. Other outcome measures varied, therefore, the use of additional outcome measures with validated measurement instruments should be considered. RELEVANCE TO CLINICAL PRACTICE: The review contributed further insight into interventions aiming at family participation in essential care activities in the intensive care unit and their outcomes. NO PATIENT OR PUBLIC CONTRIBUTION: Neither patients nor public were involved.

Patient factors associated with conveyance decision-making by Emergency Medical Services professionals in patients with a syncope: a cross-sectional factorial survey design.

BACKGROUND: The clinical decision-making of non-conveyance is perceived as complex and difficult by emergency medical services (EMS) professionals. Patients with a transient loss of consciousness (TLOC) based on syncope constitute a significant part of the non-conveyance population. Risk stratification is the basis of the clinical decision-making process by EMS professionals. This risk stratification is based on various patient factors. This study aimed to explore patient factors significantly associated with conveyance decision-making by EMS professionals in patients with a TLOC based on syncope. METHODS: A cross-sectional vignette study with a factorial survey design was conducted. Patient factors were derived from the "National Protocol Ambulance Care", and all possible combinations of these factors and underlying categories were combined, resulting in 256 unique vignettes (2*4*4*4*2 = 256). Patient factors presented either low-risk or high-risk factors for adverse events. Data were collected through an online questionnaire, in which participants received a random sample of 15 vignettes. For each vignette, the respondent indicated whether the patient would need to be conveyed to the emergency department or not. A multilevel logistic regression analysis with stepwise backward elimination was performed to analyse factors significantly associated with conveyance decision-making. In the logistic model, we modelled the probability of non-conveyance. RESULTS: 110 respondents were included, with 1646 vignettes being assessed. Mean age 45.5 (SD 9.3), male gender 63.6%, and years of experience 13.2 (SD 8.9). Multilevel analysis showed two patient factors contributing significantly to conveyance decision-making: 'red flags' and 'prehospital electrocardiogram (ECG)'. Of these patient factors, three underlying categories were significantly associated with non-conveyance: 'sudden cardiac death < 40 years of age in family history' (OR 0.33, 95% CI 0.22-0.50; p < 0.001), 'cardiovascular abnormalities, pulmonary embolism or pulmonary hypertension in the medical history' (OR 0.62, 95% CI 0.43-0.91; p = 0.01), and 'abnormal prehospital ECG' (OR 0.54, 95% CI 0.41-0.72; p < 0.001). CONCLUSION: Sudden cardiac death < 40 years of age in family history, medical history, and abnormal ECG are significantly negatively associated with non-conveyance decision-making by EMS professionals in patients with a TLOC based on syncope. Low-risk factors do not play a significant role in conveyance decision-making.

Family participation in essential care activities: Needs, perceptions, preferences, and capacities of intensive care unit patients, relatives, and healthcare providers-An integrative review.

BACKGROUND: Family participation in essential care activities may benefit both patients and relatives. OBJECTIVES: In this integrative review, we aimed to identify needs, perceptions, preferences, and capacities regarding family participation in essential care in intensive care units (ICUs) from the patient's, relatives', and ICU healthcare providers' perspective. REVIEW METHOD USED: An integrative review method was used. DATA SOURCES: PubMed, CINAHL, EMBASE, MEDLINE, Cochrane, Web of Science, and reference lists of included articles were searched, from inception to January 25, 2021. REVIEW METHODS: We included studies on family participation in essential care activities during ICU stay which reported associated needs, perceptions, preferences and capacities. Quality assessment was performed with the Kmet Standard Quality Assessment Criteria developed for evaluating primary research papers in a variety of fields, and an extensive qualitative thematic analysis was performed on the results. RESULTS: Twenty-seven studies were included. Quality scores varied from 0.45 to 0.95 (range: 0-1). Patients' needs, perceptions, preferences, and capacities are largely unknown. Identified themes on needs and perceptions were relatives' desire to help the patient, a mostly positive attitude among all involved, stress regarding patient safety, perceived beneficial effects, relatives feeling in control-ICU healthcare providers' concerns about loss of control. Preferences for potential essential care activities vary. Relatives want an invitation and support from ICU healthcare providers. Themes regarding capacities were knowledge, skills, education and training, and organisational conditions. CONCLUSIONS: Implementation of family participation in essential care requires education and training of relatives and ICU healthcare providers to address safety and quality of care concerns, though most studies lack further specification.

Starting ambulance care professionals and critical incidents: a qualitative study on experiences, consequences and coping strategies.

BACKGROUND: Ambulance care professionals are regularly confronted with critical incidents that increase risks for mental health disorders. To minimize these risks, it is important that ambulance care professionals adequately cope with critical incidents. Especially from the perspective of starting ambulance care professionals it is unknown which coping styles they use when experiencing a critical incident and how they are trained to cope with critical incidents. The aim of this study was to gain insight in (a) what starting ambulance care professionals describe as critical incidents, (b) how they experience these critical incidents and their consequences, (c) how they cope with these incidents, and (d) how they are trained and guided to cope with these incidents. METHODS: A qualitative design with individual, semi-structured interviews was used. The data was analyzed by using inductive thematic analysis. RESULTS: Twenty-two starting ambulance care professionals were interviewed of which, 11 were male. The age ranged from 23 to 31 years, with 11 participants being 27 years or younger. Three key-themes emerged that make an incident critical: (1) emotional connection versus emotional detachment, (2) feeling loss of control, and (3) incomprehension. All participants experienced several short to middle term physical, psychological and social consequences after encountering a critical incident. Starting ambulance care professionals applied different coping strategies during different phases of the ambulance care process: a mix of depersonification, focus on the medical task, support from colleagues and their own network, seeking confirmation, and distraction. Most starting ambulance care professionals don't actively remember they received education about coping with critical incidents during their initial educational program. During and after traineeships, the workplace preceptor has a crucial role for starting ambulance care professionals to learn them how to cope with critical incidents. CONCLUSIONS: Three key-themes interact to make an incident more critical for starting ambulance care professionals. To cope with these critical incidents, starting ambulance care professionals use a variety of coping strategies. These results can be used to develop training and coaching for starting ambulance care professionals so they can adequately cope with critical incidents.

Older persons are frailer after an emergency care visit to the out-of-hours general practitioner cooperative in the Netherlands: a cross-sectional descriptive TOPICS-MDS study.

BACKGROUND: In the Netherlands, community-dwelling older people with primary care emergency problems contact the General Practitioner Cooperative (GPC) after hours. However, frailty remains an often unobserved hazard with adverse health outcomes. The aim of this study was to provide insight into differences between older persons with or without GPC emergency care visits (reference group) regarding frailty and healthcare use. METHODS: A cross-sectional descriptive study design was based on data from the public data repository of The Older Persons and Informal Caregivers Survey Minimum Dataset (TOPICS-MDS). Frailty in older persons (65+ years, n = 32,149) was measured by comorbidity, functional and psychosocial aspects, quality of life and a frailty index. Furthermore, home care use and hospital admissions of older persons were identified. We performed multilevel logistic and linear regression analyses. A random intercept model was utilised to test differences between groups, and adjustment factors (confounders) were used in the multilevel analysis. RESULTS: Compared to the reference group, older persons with GPC contact were frailer in the domain of comorbidity (mean difference 0.52; 95% CI 0.47-0.57, p < 0.0001) and functional limitations (mean difference 0.53; 95% CI 0.46-0.60, p < 0.0001), and they reported less emotional wellbeing (mean difference - 4.10; 95% CI -4.59- -3.60, p < 0.0001) and experienced a lower quality of life (mean difference - 0.057; 95% CI -0.064- -0.050, p < 0.0001). Moreover, older persons more often reported limited social functioning (OR = 1.50; 95% CI 1.39-1.62, p < 0.0001) and limited perceived health (OR = 1.50, 95% CI 1.39-1.62, p < 0.0001). Finally, older persons with GPC contact more often used home care (OR = 1.37; 95% CI 1.28-1.47, p < 0.0001) or were more often admitted to the hospital (OR = 2.88; 95% CI 2.71-3.06, p < 0.0001). CONCLUSIONS: Older persons with out-of-hours GPC contact for an emergency care visit were significantly frailer in all domains and more likely to use home care or to be admitted to the hospital compared to the reference group. Potentially frail older persons seemed to require adequate identification of frailty and support (e.g., advanced care planning) both before and after a contact with the out-of-hours GPC.

Effectiveness of supporting intensive care units on implementing the guideline 'End-of-life care in the intensive care unit, nursing care': a cluster randomized controlled trial.

AIM: The aim of this study was to examine the effectiveness of supporting intensive care units on implementing the guidelines. BACKGROUND: Quality of care can be achieved through evidence-based practice. Guidelines can facilitate evidence-based practice, such as the guidelines 'End-of-life care in the intensive care unit, nursing care'. Before intensive care nurses are able to use these guidelines, they needs to be implemented in clinical practice. Implementation is a complex process and may need support. DESIGN: Cluster randomized controlled trial. METHODS: Intensive care nurses of eight intensive care units in the intervention group followed a supportive programme that educated them on implementation, strategies, goals, project management and leadership. The intervention group focused on a stepwise approach to implement the guidelines. The control group (n = 5) implemented the guidelines independently or used the standard implementation plan supplementary to the guideline. The effectiveness of the programme was measured using questionnaires for nurses, interviews with nurses and a questionnaire for family of deceased patients, in the period from December 2014-December 2015. RESULTS: Overall, an increase in adherence to the guidelines was found in both groups. Overall, use of the guidelines in the intervention group was higher, but on some aspects the control group showed a higher score. Care for the patient and the overall nursing care scored significantly higher according to family in the intervention group. CONCLUSION: The increase in adherence to the guidelines and the significantly higher satisfaction of family in the intervention group indicate that the supportive programme had a more positive effect.

The role of ICU nurses in the spiritual aspects of end-of-life care in the ICU: an explorative study.

AIM: The aim of this study was to examine the role and responsibilities of intensive care unit (ICU) nurses regarding the spiritual aspects of end-of-life care in the ICU, from the chaplains' perspectives. METHOD: An explorative study including inductive thematic analysis was used. Two focus group interviews with in total eleven chaplains working in several Dutch ICUs were performed. RESULTS: The focus group interviews resulted in five themes: (i) awareness of ICU nurses, (ii) communication, (iii) nursing interventions, (iv) multidisciplinary care and (v) education. In total, twenty recommendations were formulated. CONCLUSIONS: This explorative study provides an overview of the perspectives of chaplains about the role of ICU nurses during end-of-life care, specified to spiritual care. Chaplains mentioned different roles, responsibilities and competences which are needed for ICU nurses to give spiritual care. These roles, responsibilities and competences included giving spiritual care to patients and families as standard care. Chaplains agreed that ICU nurses should start and maintain a dialogue with patient and families, but that it is also important to be aware of one's own spiritual background. However, education about spiritual care is needed to establish this. It could be recommended to educate ICU nurses during their ICU training or retraining about spiritual care and reflection.

The nursing role during end-of-life care in the intensive care unit related to the interaction between patient, family and professional: an integrative review.

AIM: The aim of this study was to explore how intensive care unit (ICU) nurses describe their role during End-of-Life Care (EOLC) in the ICU, related to the interaction between patient, family and professionals (care triad). METHOD: Three electronic databases, PubMed, CINAHL and EMBASE, and reference lists of included studies were searched for studies in English, Dutch or German between January 2002 and August 2015. Studies were included if they presented data about EOLC in the adult ICU, and the role of ICU nurses around EOLC. Quantitative and qualitative studies and opinion articles were extracted. Inductive content analysis was carried out to analyse and categorise the data. RESULTS: Twenty studies were included. Four categories emerged: care for the ICU patient, care for the family, environmental aspects of EOLC and organisational aspects of EOLC. Regarding the care triad, a gap exists between theoretical models and the actual care provided by ICU nurses during EOLC. The relational aspect of care, like aimed with care triad, is absent. CONCLUSION: The literature clearly indicates that the role of ICU nurses concerns care for the patient, family and environment. It described which care should be given, but it remains unclear how care should be given (attitude). Therefore, it is difficult for ICU nurses to provide this care. Further, it seems that care provided to family mainly consists of giving advice on how to care for the patient; care for family members themselves was only mentioned in a few studies. Therefore, it seems that family does not always receive adequate care yet, which may be helpful in preventing problems like depression, anxiety or post-traumatic stress disorder. It can be concluded that it is important for ICU nurses to be aware of the existing relationships; however, comparing the literature, care triad does not appear to be reached.

An exploration of factors influencing ambulance and emergency nurses' protocol adherence in the Netherlands.

INTRODUCTION: Adherence to ambulance and ED protocols is often suboptimal. Insight into factors influencing adherence is a requisite for improvement of adherence. This study aims to gain an in-depth understanding of factors that influence ambulance and emergency nurses' adherence to protocols. METHODS: Semi-structured interviews were held with ambulance nurses, emergency nurses, and physicians (N = 20) with medical end responsibility in the Netherlands to explore influencing factors. Content analysis was used to identify influencing factors. RESULTS: The main influencing factors for adherence were individual factors, including individual (clinical) experience, awareness, and the preference of following local protocols instead of national protocols. Organizational or external factors were involvement in protocol development, training and education, control mechanisms for adherence, and physicians' interest. Also of influence were protocol characteristics including integration of the advanced trauma life support approach, being in accordance with daily practice, and the generality of the content. Influencing factors could be a barrier as well as a facilitator for adherence. DISCUSSION: Factors influencing ambulance and emergency nurses' protocol adherence could be assigned to individual, organizational, and external categories, as well as to protocol characteristics. To improve adherence, implementation strategies should be tailored to identified factors. Multifaceted implementation strategies will be needed to improve adherence.

[What to do when elder abuse is suspected?] / Wat te doen als je ouderenmishandeling vermoedt?

Elder abuse is a worldwide problem with serious consequences for individuals and society. The recognition of elder abuse is complex due to a lack of awareness and knowledge. We present a case of a patient with signs of elder abuse. This case concerns a patient who showed signs of neglect and physical abuse as a result of possible derailed informal care provision. The mandatory reporting code on domestic violence of The Royal Dutch Medical Association was followed and measures were taken by the general practitioner. In the discussion, information on signs and types of elder abuse were provided, together with the description of risk factors.

Exploring patients' and relatives' needs and perceptions regarding family participation in essential care in the intensive care unit: A qualitative study.

OBJECTIVES: To examine the needs, perceptions and influencing factors according to former adult intensive care unit patients and relatives with regard to family participation in essential care in the unit. RESEARCH DESIGN: A qualitative interpretive descriptive study using inductive thematic analysis. SETTING: Twelve pairs of former Dutch patients and their relatives were interviewed within two months after the patient's discharge from the unit between December 2017 and April 2018. FINDINGS: Four themes emerged: the family's history, the patient's condition, supporting the patient and supporting the relative. The family's history, in particular the relationship with the patient and former experience with care, determined the level of participation in essential care. The level of participation was also influenced by the patient's condition, more specifically level of consciousness, stability of the patient's situation and length of the patient's stay. The third theme, supporting the patient, related to presence/being able to 'be there' for the patient and a mostly positive attitude towards family participation. The last theme was supporting the relative, with three subthemes associated with relatives' needs and perceptions: (dis)comfort with participation in essential care, need for invitation and support, and concern about the possible strain experienced by relatives. CONCLUSION: Supporting the patient and supporting the relative are reflecting the needs and perceptions of patients and relatives regarding family participation in essential care. Both the family's history and the patient's condition influence the relative's level of participation. Intensive care unit nurses and other healthcare providers could take these themes into account when encouraging family participation in essential care. IMPLICATIONS FOR CLINICAL PRACTICE: Patients' and relatives' needs and perceptions of family participation in essential care in the intensive care unit vary. Family participation in essential care is influenced by the family's history and the patient's condition. Healthcare providers could take these findings into account when implementing family participation in essential care.

The impact of COVID-19 on the mental health and well-being of ambulance care professionals: A rapid review.

The COVID-19 pandemic has a significant impact on the health and well-being of all healthcare professionals. However, for ambulance care professionals it is unknown on which health outcomes the impact of COVID-19 is measured, and what the actual impact on these health outcomes is. Therefore, the aim of this study was to gain insight in a) which type of health outcomes were measured in relation to the impact of COVID-19 among ambulance care professionals, and b) to determine the actual impact on these outcomes. A rapid review was performed in PubMed (including MEDLINE) and APA PsycInfo (EBSCO). All types of study designs on health and well-being of ambulance care professionals were included. Selection on title an abstract was performed by pairs of two reviewers. Full text selection, data extraction and quality assessment were performed by one reviewer, with a check by a second independent reviewer. The systematic searches identified 3906 unique hits, seven articles meeting selection criteria were included. Six studies quantitatively measured distress (36,0%) and PTSD (18.5%-30.9%), anxiety (14.2%-65.6%), depression (12.4%-15.3%), insomnia (60.9%), fear of infection and transmission of infection (41%-68%), and psychological burden (49.4%-92.2%). These studies used a variety of instruments, ranging from internationally validated instruments to self-developed and unvalidated questionnaires. One study qualitatively explored coping with COVID-19 by ambulance care professionals and reported that ambulance care professionals use five different strategies to cope with the impact of COVID-19. There is limited attention for the health and well-being of ambulance care professionals during the COVID-19 pandemic. Although the included number of studies and included outcomes are too limited to draw strong conclusions, our results indicate higher rates of distress, PTSD and insomnia compared to the pre-COVID-19 era. Our results urge the need to investigate the health and well-being of ambulance care professionals during and after the COVID-19 pandemic.

Risk stratification tools for patients with syncope in emergency medical services and emergency departments: a scoping review.

BACKGROUND: Patients with a syncope constitute a challenge for risk stratification in (prehospital) emergency care. Professionals in EMS and ED need to differentiate the high-risk from the low-risk syncope patient, with limited time and resources. Clinical decision rules (CDRs) are designed to support professionals in risk stratification and clinical decision-making. Current CDRs seem unable to meet the standards to be used in the chain of emergency care. However, the need for a structured approach for syncope patients remains. We aimed to generate a broad overview of the available risk stratification tools and identify key elements, scoring systems and measurement properties of these tools. METHODS: We performed a scoping review with a literature search in MEDLINE, CINAHL, Pubmed, Embase, Cochrane and Web of Science from January 2010 to May 2022. Study selection was done by two researchers independently and was supervised by a third researcher. Data extraction was performed through a data extraction form, and data were summarised through descriptive synthesis. A quality assessment of included studies was performed using a generic quality assessment tool for quantitative research and the AMSTAR-2 for systematic reviews. RESULTS: The literature search identified 5385 unique studies; 38 were included in the review. We discovered 19 risk stratification tools, one of which was established in EMS patient care. One-third of risk stratification tools have been validated. Two main approaches for the application of the tools were identified. Elements of the tools were categorised in history taking, physical examination, electrocardiogram, additional examinations and other variables. Evaluation of measurement properties showed that negative and positive predictive value was used in half of the studies to assess the accuracy of tools. CONCLUSION: A total of 19 risk stratification tools for syncope patients were identified. They were primarily established in ED patient care; most are not validated properly. Key elements in the risk stratification related to a potential cardiac problem as cause for the syncope. These insights provide directions for the key elements of a risk stratification tool and for a more advanced process to validate risk stratification tools.

Types, characteristics and anatomic location of physical signs in elder abuse: a systematic review : Awareness and recognition of injury patterns.

PURPOSE: Elder abuse is a worldwide problem with serious consequences for individuals and society. The recognition of elder abuse is complex due to a lack of awareness and knowledge. In this systematic review, types, characteristics and anatomic location of physical signs in elder abuse were identified. METHODS: Databases of MEDLINE, COCHRANE, EMBASE and CINAHL were searched. The publication dates ranged from March 2005 to July 2020. In addition to the electronic searches, the reference lists and citing of included articles were hand-searched to identify additional relevant studies. The quality of descriptive and mixed-methods studies was assessed. RESULTS: The most commonly described physical signs in elder abuse were bruises. The characteristics of physical signs can be categorized into size, shape and distribution. Physical signs were anatomically predominantly located on the head, face/maxillofacial area (including eyes, ears and dental area), neck, upper extremities and torso (especially posterior). Physical signs related to sexual elder abuse were mostly located in the genital and perianal area and often accompanied by a significant amount of injury to non-genital parts of the body, especially the area of the head, arms and medial aspect of the thigh. CONCLUSIONS: Most common types, characteristics and anatomic location of physical signs in elder abuse were identified. To enhance (early) detection of physical signs in elder abuse, it is necessary to invest in (more) in-depth education and to include expertise from a forensic physician or forensic nurse in multidisciplinary team consultations.

A Quality Improvement Project to Support Post-Intensive Care Unit Patients with COVID-19: Structured Telephone Support.

BACKGROUND: More than 50% of intensive care unit (ICU) survivors suffer from long-lasting physical, psychosocial, and cognitive health impairments, also called "post-intensive care syndrome" (PICS). Intensive care admission during the COVID-19 pandemic was especially uncertain and stressful, both for patients and for their family. An additional risk of developing symptoms of PICS was feared in the absence of structural aftercare for the patient and family shortly after discharge from the hospital. The purpose of this quality improvement study was to identify PICS symptoms and to support post-intensive care patients and families in the transition from the hospital to the home. Therefore, we offered post-ICU patients and families structured telephone support (STS). METHODS: This was a quality improvement study during the 2019 COVID-19 pandemic. A project team developed and implemented a tool to structure telephone calls to identify and order symptoms according to the PICS framework and to give individual support based on this information. We supported post-ICU patients diagnosed with COVID-19 pneumonia and their family caregivers within four weeks after hospital discharge. The reported findings were both quantitative and qualitative. RESULTS: Forty-six post-ICU patients received structured telephone support and reported symptoms in at least one of the three domains of the PICS framework. More than half of the patients experienced a loss of strength or condition and fatigue. Cognitive and psychological impairments were reported less frequently. Family caregivers reported fewer impairments concerning fatigue and sleeping problems and expressed a need for a continuity of care. Based on the obtained information, the ICU nurse practitioners were able to check if individual care plans were optimal and clear and, if indicated, initiated disciplines to optimize further follow-up. CONCLUSIONS: The implementation of the STS tool gave insight in the impairments of post-ICU patients. Surprisingly, family caregivers expressed fewer impairments. Giving support early after hospital discharge in a structured way may contribute to providing guidance in the individual care plans and treatment of the early symptoms of PICS (-F).

Medical Coordination Rescue Members' and Ambulance Nurses' Perspectives on a New Model for Mass Casualty and Disaster Management and a Novel Terror Attack Mitigation Approach in the Netherlands: A Qualitative Study.

INTRODUCTION: Mass-casualty incidents (MCIs), specifically incidents with chemical, biological, radiological, and nuclear agents (CBRN) or terrorist attacks, challenge medical coordination, rescue, availability, and adequate provision of prehospital and hospital-based emergency care. In the Netherlands, a new model for Mass Casualty and Disaster Management (MCDM) along with a Terror Attack Mitigation Approach (TAMA) was introduced in 2016. STUDY OBJECTIVE: The objective of this study was to provide insight in the first experiences of health policy advisors and managers with a medical rescue coordinator and ambulance nursing background regarding the new MCDM and TAMA in order to identify strengths and pitfalls in emergency preparedness and to provide recommendations for improvement. METHODS: The study had a qualitative design and was performed from January 2017 through June 2018. Purposeful sampling was used and the inclusion comprehended health policy advisors and managers with a medical rescue coordinator and ambulance nursing background involved in emergency preparedness. The respondents were interviewed semi-structured and the researchers used a topic list that was based on the literature and content of the newly introduced model and approach. All interviews were typed out verbatim and qualitative content analyzing was used in order to identify relevant themes. RESULTS: Respondents based their perceptions on large-scale training exercises, as MCDM and TAMA were not yet used during MCIs. Perceived issues of MCDM were the two-tiered triage system, the change in focus from "stay and play" towards "scoop and run," difficulties with new tasks and roles of professionals, and improvement in material provision. Regarding TAMA, all respondents supported the principles (do the most for the most; scoop and run; acceptable personal risk; never walk alone; and standard operational procedure); however, the definitions were lacking clarity while the awareness of optimal personal safety of professionals was absent.As there are currently regional differences in the level of implementation of MCDM and TAMA, this may pose a risk for an optimal inter-regional collaboration. CONCLUSION: The conclusions refer to experiences of professionals in the Netherlands. Elements of the MCDM and TAMA were highly appreciated and seemed to improve emergency preparedness, while other aspects needed further attention, training, and integration in daily routine. The Netherlands' MCDM model and TAMA will need continuous systematic evaluation based on (inter)national performance criteria in order to underpin the useful and effective elements and to improve the observed pitfalls in emergency preparedness.