Mortality among head trauma patients taking preinjury antithrombotic agents: a retrospective cohort analysis from a Level 1 trauma centre.

BACKGROUND: Bleeding represents the most well-known and the most feared complications caused by the use of antithrombotic agents. There is, however, limited documentation whether pre-injury use of antithrombotic agents affects outcome after head trauma. The aim of this study was to define the relationship between the use of preinjury antithrombotic agents and mortality among elderly people sustaining blunt head trauma. METHODS: A retrospective cohort analysis was performed on the hospital based trauma registry at Oslo University Hospital. Patients aged 55 years or older sustaining blunt head trauma between 2004 and 2006 were included. Multivariable logistic regression analyses were used to identify independent predictors of 30-day mortality. Separate analyses were performed for warfarin use and platelet inhibitor use. RESULTS: Of the 418 patients admitted with a diagnosis of head trauma, 137 (32.8 %) used pre-injury antithrombotic agents (53 warfarin, 80 platelet inhibitors, and 4 both). Seventy patients died (16.7 %); 15 (28.3 %) of the warfarin users, 12 (15.0 %) of the platelet inhibitor users, and two (50 %) with combined use of warfarin and platelet inhibitors, compared to 41 (14.6 %) of the non-users. There was a significant interaction effect between warfarin use and the Triage Revised Trauma Score collected upon the patients' arrival at the hospital. After adjusting for potential confounders, warfarin use was associated with increased 30-day mortality among patients with normal physiology (adjusted OR 8,3; 95 % CI, 2.0 to 34.8) on admission, but not among patients with physiological derangement on admission. Use of platelet inhibitors was not associated with increased mortality. CONCLUSIONS: The use of warfarin before trauma was associated with increased 30-day mortality among a subset of patients. Use of platelet inhibitors before trauma was not associated with increased mortality. These results indicate that patients on preinjury warfarin may need closer monitoring and follow up after trauma despite normal physiology on admission to the emergency department.

Job Satisfaction and Burnout among Intensive Care Unit Nurses and Physicians.

Introduction. Nurses and physicians working in the intensive care unit (ICU) may be exposed to considerable job stress. The study aim was to assess the level of and the relationship between (1) job satisfaction, (2) job stress, and (3) burnout symptoms. Methods. A cross-sectional study was performed at ICUs at Oslo University Hospital. 145 of 196 (74%) staff members (16 physicians and 129 nurses) answered the questionnaire. The following tools were used: job satisfaction scale (scores 10-70), modified Cooper's job stress questionnaire (scores 1-5), and Maslach burnout inventory (scores 1-5); high score in the dimension emotional exhaustion (EE) indicates burnout. Personality was measured with the basic character inventory. Dimensions were neuroticism (vulnerability), extroversion (intensity), and control/compulsiveness with the range 0-9. Results. Mean job satisfaction among nurses was 43.9 (42.4-45.4) versus 51.1 (45.3-56.9) among physicians, P < 0.05. The mean burnout value (EE) was 2.3 (95% CI 2.2-2.4), and mean job stress was 2.6 (2.5-2.7), not significantly different between nurses and physicians. Females scored higher than males on vulnerability, 3.3 (2.9-3.7) versus 2.0 (1.1-2.9) (P < 0.05), and experienced staff were less vulnerable, 2.7 (2.2-3.2), than inexperienced staff, 3.6 (3.0-4.2) (P < 0.05). Burnout (EE) correlated with job satisfaction (r = -0.4, P < 0.001), job stress (r = 0.6, P < 0.001), and vulnerability (r = 0.3, P = 0.003). Conclusions. The nurses were significantly less satisfied with their jobs compared to the physicians. Burnout mean scores are relatively low, but high burnout scores are correlated with vulnerable personality, low job satisfaction, and high degree of job stress.

Satisfaction with communication in ICU patients and relatives: comparisons with medical staffs' expectations and the relationship with psychological distress.

OBJECTIVE: To study intensive care unit (ICU) patients' and relatives' satisfaction in regard to communication with medical staff (nurses and physicians), perceived support, environmental strain and their psychological distress. Further, to compare this with expectations of the medical staff. METHODS: Cross-sectional study, 4-6 weeks post-ICU discharge. Respondents to the questionnaire were: 255 (63%) patients, 354 (82%) relatives and 145 (74%) medical staff. Degree of satisfaction and distress were measured on a five-point Likert-scale (0=low to 4=high). RESULTS: The mean score for patient satisfaction with communication was 3.0 (95%CI 2.9-3.1) and for relatives 3.4 (3.3-3.5). This was significantly higher than expected by the staff for patients 2.5 (2.4-2.6) and relatives 2.8 (2.7-2.9), both p<0.001. Relatives' degree of psychological distress, 2.5 (2.4-2.6) was significantly higher than for patients', 1.6 (1.5-1.7), but was significantly lower than expected by the staff, 2.9 (2.8-3.0) and 2.7 (2.6-2.8) respectively, both p<0.001. CONCLUSION: Patients and relatives were more satisfied with the communication than expected by the staff. The staff overestimated the patients' and relatives' psychological distress. Relatives report more psychological distress symptoms post-ICU discharge compared to the patients. PRACTICE IMPLICATIONS: Medical staff is aware of psychological distress in ICU patients and relatives and effort to reduce this during ICU stay and afterwards should be implemented.

Health-related quality of life and return to work after critical illness in general intensive care unit patients: a 1-year follow-up study.

OBJECTIVE: To study how health-related quality of life of intensive care unit survivors compares with the general population, changes over time, and association with an optimistic personality trait and posttraumatic stress. Further, to explore differences in health-related quality of life between medical, trauma, and surgical patients and to assess return to work/school at 1 yr. DESIGN: Prospective 1-yr follow-up study. SETTING: University-affiliated trauma center hospital. PATIENTS: At 1-yr, 194 patients participated. Mean age was 49 yrs and 60% were males. MEASUREMENTS AND MAIN RESULTS: Health-related quality of life was assessed by the Short Form 36, which measures health-related quality of life in eight separate dimensions (0=worst health state, 100=best health state). At 1 yr, significantly lower scores compared to the general population were seen in all eight scales (p<.001). The decrease in Short Form 36 scores between before intensive care unit and 1-yr measurements was significant for all eight dimensions (p<.01). The multivariate regression analyses adjusted for gender, age (beta, -0.3), optimism (beta, 0.9), medical disease (beta, 12.2), length of stay in intensive care unit (beta, -0.4), being employed/student/retired before intensive care unit stay (beta, 12.5), and posttraumatic stress symptoms (beta, -9.1; all p<.05) were independent predictors of the dimension physical functioning (adjusted r=.22). For mental health, adjusted for age and gender, independent predictors were optimism (beta, 1.4), being employed/student/retired before intensive care unit stay (beta, 14.9), and posttraumatic stress symptoms (beta, -11.6; all p<.001; adjusted r=.35). Before intensive care unit admission, 122 (63%) patients were students/working, among these, 67 (55%) had returned to work/school at 1-yr follow-up. CONCLUSION: Intensive care unit survivors had significantly lower health-related quality of life at 1 yr compared to the general population and significantly reduced compared to their states before intensive care unit admission. Less posttraumatic stress and optimism were predictors of higher health-related quality of life and return to work/school. Trauma patients had the largest decrease in both physical and mental scores. Only half of the patients had returned to work/school.

Posttraumatic stress, anxiety and depression symptoms in patients during the first year post intensive care unit discharge.

INTRODUCTION: To study the level and predictors of posttraumatic stress, anxiety and depression symptoms in medical, surgical and trauma patients during the first year post intensive care unit (ICU) discharge. METHODS: Of 255 patients included, 194 participated at 12 months. Patients completed the Impact of Event Scale (IES), Hospital Anxiety and Depression Scale (HADS), Life Orientation Test (LOT) at 4 to 6 weeks, 3 and 12 months and ICU memory tool at the first assessment (baseline). Case level for posttraumatic stress symptoms with high probability of a posttraumatic stress disorder (PTSD) was > or = 35. Case level of HADS-Anxiety or Depression was > or = 11. Memory of pain during ICU stay was measured at baseline on a five-point Likert-scale (0-low to 4-high). Patient demographics and clinical variables were controlled for in logistic regression analyses. RESULTS: Mean IES score one year after ICU treatment was 22.5 (95%CI 20.0 to 25.1) and 27% (48/180) were above case level, IES > or = 35. No significant differences in the IES mean scores across the three time points were found (P = 0.388). In a subgroup, 27/170 (16%), patients IES score increased from 11 to 32, P < 0.001. No differences in posttraumatic stress, anxiety or depression between medical, surgical and trauma patients were found. High educational level (OR 0.4, 95%CI 0.2 to 1.0), personality trait (optimism) OR 0.9, 95%CI 0.8 to 1.0), factual recall (OR 6.6, 95%CI 1.4 to 31.0) and memory of pain (OR 1.5, 95%CI 1.1 to 2.0) were independent predictors of posttraumatic stress symptoms at one year. Optimism was a strong predictor for less anxiety (OR 0.8, 0.8 to 0.9) and depression symptoms (OR 0.8, 0.8 to 0.9) after one year. CONCLUSIONS: The mean level of posttraumatic stress symptoms in patients one year following ICU treatment was high and one of four were above case level Predictors of posttraumatic stress symptoms were mainly demographics and experiences during hospital stay whereas clinical injury related variables were insignificant. Pessimism was a predictor of posttraumatic stress, anxiety and depression symptoms. A subgroup of patients developed clinically significant distress symptoms during the follow-up period.

Patients' memory and psychological distress after ICU stay compared with expectations of the relatives.

PURPOSE: To compare patients' psychological distress and memories from intensive care unit (ICU) treatment 4-6 weeks after ICU discharge with expectations of their relatives. Further, to explore the relationship between personality traits and ICU memories with psychological distress. METHODS: A cross-sectional study of 255 patients and 298 relatives. The questionnaire included: hospital anxiety and depression scale (HADS), impact of event scale (IES), life orientation test, ICU memory tool and memory of ICU; technical procedures, pain, lack of control and inability to express needs. Relatives were assessed for their expectations of the patients' memories and psychological distress. RESULTS: Twenty-five percent of the patients reported severe posttraumatic stress symptoms, IES-total >or= 35. The levels of anxiety and depression were significantly higher than in the general population, mean anxiety was 5.6 versus 4.2 (p < 0.001), and mean depression was 4.8 versus 3.5 (p < 0.001). Relatives expected more psychological distress and the relatives thought the patient was less able to express needs than the patients reported (p < 0.001). Higher age, unemployment, respirator treatment, pessimism, memory of pain, lack of control and inability to express needs were independent predictors of posttraumatic stress symptoms (p < 0.01). CONCLUSIONS: Psychological distress symptoms were frequent among ICU survivors. Relatives expected the patients to be more distressed after ICU treatment than the patients reported. The strongest predictors of posttraumatic stress symptoms from the ICU were memoris about pain, lack of control and inability to express needs. Pessimism may be a reason for psychological distress and should be addressed during follow up, as pessimistic patients may need more motivation and support.

Patient's satisfaction and distress compared with expectations of the medical staff.

OBJECTIVE: Patient satisfaction is increasingly used to measure and evaluate patient treatment in hospital. The aim of this study is to assess satisfaction regarding communication, support and the degree of anxiety and depression among the patients, and to compare reports from the patients with the expectations of the staff. METHODS: In a prospective study, 176 (93%) of the patients and 52 (80%) of the nurses completed a similar questionnaire. Degree of satisfaction was measured on a five-point scale (0-4), and degree of anxiety and depression was measured with the hospital anxiety and depression scale (HAD). RESULTS: Satisfaction regarding communication with nurses (3.4+/-0.07) and physicians (3.0+/-0.08) was higher than expected by the staff (2.9+/-0.09 and 2.4+/-0.09, respectively) (p<0.01). The staff expected a higher degree of anxiety (2.3+/-0.10 versus 1.5+/-0.12) (p<0.01). The patients scored significantly higher on HAD anxiety compared with the population in general. The HAD score correlated negatively with the level of satisfaction. CONCLUSION: The patients generally showed a high degree of satisfaction with communication and support. The staff underestimated the patients' degree of satisfaction and overestimated their degree of anxiety. PRACTICE IMPLICATIONS: Knowledge of patients' degree of satisfaction is important for satisfactory communication with the staff, compliance with treatment and in order to reduce staff's concern for their care.

Emotional strain, communication, and satisfaction of family members in the intensive care unit compared with expectations of the medical staff: experiences from a Norwegian University Hospital.

OBJECTIVES: To determine satisfaction in regard to information concerning, and support and facilities for relatives in the intensive care unit (ICU), and to compare this with the staff's expectations on these issues; to determine relatives' degree of psychological distress and use of hypnotics, anxiolytics, and antidepressants; finally, to compare the distress of relatives of survivors and relatives of non-survivors. DESIGN: Prospective study. SETTING: University-affiliated ICU. METHODS: Relatives of 50 patients who survived at least 6 days in the ICU and relatives of 18 non-survivors who stayed for at least 24 h anonymously completed a mailed questionnaire at home 4 weeks after treatment in the ICU. Forty-three staff members (69%) answered the questionnaire. The degree of satisfaction was measured on a five-point scale (0-4). MAIN RESULTS: The average satisfaction scores were 3.4+/-0.6 SD for relatives of survivors and 3.4+/-0.5 for relatives of non-survivors. Staff expected a significantly lower degree of satisfaction, with a score of 2.9+/-0.5 (P<0.001). The distress scores of relatives of survivors (2.7+/-1.0) were no higher than the ones of relatives of non-survivors (2.4+/-0.6) during the ICU stay, but significantly lower than staff expectations (3.2+/-0.5) (P<0.01). The use of medication was moderate. CONCLUSIONS: The relatives' satisfaction was greater than anticipated by the staff. Staff generally expected a higher degree of distress among relatives than was actually the case. Relatives were very satisfied with the support and communication in the ICU despite substantial distress. Relatives of survivors and non-survivors were equally satisfied.