Psychological Outcomes in Family Members of Patients With Acute Respiratory Failure: Does Inter-ICU Transfer Play a Role?

BACKGROUND: Family members of patients admitted to the ICU experience a constellation of sequelae described as postintensive care syndrome-family. The influence that an inter-ICU transfer has on psychological outcomes is unknown. RESEARCH QUESTION: Is inter-ICU transfer associated with poor psychological outcomes in families of patients with acute respiratory failure? STUDY DESIGN AND METHODS: Cross-sectional observational study of 82 families of patients admitted to adult ICUs (tertiary hospital). Data included demographics, admission source, and outcomes. Admission source was classified as inter-ICU transfer (n = 39) for patients admitted to the ICU from other hospitals and direct admit (n = 43) for patients admitted from the ED or the operating room of the same hospital. We used quantitative surveys to evaluate psychological distress (Hospital Anxiety and Depression Scale [HADS]) and posttraumatic stress (Post-Traumatic Stress Scale; PTSS) and examined clinical, family, and satisfaction factors associated with psychological outcomes. RESULTS: Families of transferred patients travelled longer distances (mean ± SD, 109 ± 106 miles) compared with those of patients directly admitted (mean ± SD, 65 ± 156 miles; P ≤ .0001). Transferred patients predominantly were admitted to the neuro-ICU (64%), had a longer length of stay (direct admits: mean ± SD, 12.7 ± 9.3 days; transferred patients: mean ± SD, 17.6 ± 9.3 days; P < .01), and a higher number of ventilator days (direct admits: mean ± SD, 6.9 ± 8.6 days; transferred: mean ± SD, 10.6 ± 9.0 days; P < .01). Additionally, they were less likely to be discharged home (direct admits, 63%; transferred, 33%; P = .08). In a fully adjusted model of psychological distress and posttraumatic stress, family members of transferred patients were found to have a 1.74-point (95% CI, -1.08 to 5.29; P = .30) higher HADS score and a 5.19-point (95% CI, 0.35-10.03; P = .03) higher PTSS score than those of directly admitted family members. INTERPRETATION: In this exploratory study, posttraumatic stress measured by the PTSS was higher in the transferred families, but these findings will need to be replicated to infer clinical significance.

Determinants of Evidence-based Practice Uptake in Rural Intensive Care Units. A Mixed Methods Study.

Rationale: Evidence-based practices promote quality care for intensive care unit patients but chronic evidence-to-practice gaps limit their reach.Objectives: To characterize key determinants of evidence-based practice uptake in the rural intensive care setting.Methods: A parallel convergent mixed methods design was used with six hospitals receiving a quality improvement intervention. Guided by implementation science principles, we identified barriers and facilitators to uptake using clinician surveys (N = 90), key informant interviews (N = 14), and an implementation tracking log. Uptake was defined as completion of eight practice change steps within 12 months. After completing qualitative and quantitative data analyses for each hospital, site, staff, and program delivery factors were summarized within and across hospitals to identify patterns by uptake status.Results: At the site level, although structural characteristics (hospital size, intensivist staffing) did not vary by uptake status, interviews highlighted variability in staffing patterns and culture that differed by uptake status. At the clinician team level, readiness and self-efficacy were consistently high across sites at baseline with time and financial resources endorsed as primary barriers. However, interviews highlighted that as initiatives progressed, differences across sites in attitudes and ownership of change were key uptake influences. At the program delivery level, mixed methods data highlighted program engagement and leadership variability by uptake status. Higher uptake sites had better training attendance; more program activities completed; and a stable, engaged, collaborative nurse and physician champion team.Conclusions: Results provide an understanding of the multiple dynamic influences on different patterns of evidence-based practice uptake and the importance of implementation support strategies to accelerate uptake in the intensive care setting.