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OBJECTIVES: To engage critical care end-users (survivors and caregivers) to describe their emotions and experiences across their recovery trajectory, and elicit their ideas and solutions for health service improvements to improve the ICU recovery experience. DESIGN: End-user engagement as part of a qualitative design using the Framework Analysis method. SETTING: The Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS: Patients and caregivers following critical illness and identified through the collaboratives. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-six interviews were conducted. The following themes were identified: 1) Emotions and experiences of patients-"Loss of former self; Experiences of disability and adaptation"; 2) Emotions and experiences of caregivers-"Emotional impacts, adopting new roles, and caregiver burden; Influence of gender roles; Adaptation, adjustment, recalibration"; and 3) Patient and caregiver-generated solutions to improve recovery across the arc of care-"Family-targeted education; Expectation management; Rehabilitation for patients and caregivers; Peer support groups; Reconnecting with ICU post-discharge; Access to community-based supports post-discharge; Psychological support; Education of issues of ICU survivorship for health professionals; Support across recovery trajectory." Themes were mapped to a previously published recovery framework (Timing It Right) that captures patient and caregiver experiences and their support needs across the phases of care from the event/diagnosis to adaptation post-discharge home. CONCLUSIONS: Patients and caregivers reported a range of emotions and experiences across the recovery trajectory from ICU to home. Through end-user engagement strategies many potential solutions were identified that could be implemented by health services and tested to support the delivery of higher-quality care for ICU survivors and their caregivers that extend from tertiary to primary care settings.
Subject(s)
Aftercare , Caregivers , Humans , Caregivers/psychology , Patient Discharge , Critical Care , Survivors/psychologyABSTRACT
OBJECTIVES: Social determinants of health (SDoH) contribute to health outcomes. We identified SDoH that were modified by critical illness, and the effect of such modifications on recovery from critical illness. DESIGN: In-depth semistructured interviews following hospital discharge. Interview transcripts were mapped against a pre-existing social policy framework: money and work; skills and education; housing, transport and neighbourhoods; and family, friends and social connections. SETTING: 14 hospital sites in the USA, UK and Australia. PARTICIPANTS: Patients and caregivers, who had been admitted to critical care from three continents. RESULTS: 86 interviews were analysed (66 patients and 20 caregivers). SDoH, both financial and non-financial in nature, could be negatively influenced by exposure to critical illness, with a direct impact on health-related outcomes at an individual level. Financial modifications included changes to employment status due to critical illness-related disability, alongside changes to income and insurance status. Negative health impacts included the inability to access essential healthcare and an increase in mental health problems. CONCLUSIONS: Critical illness appears to modify SDoH for survivors and their family members, potentially impacting recovery and health. Our findings suggest that increased attention to issues such as one's social network, economic security and access to healthcare is required following discharge from critical care.
Subject(s)
Critical Illness , Social Determinants of Health , Caregivers/psychology , Critical Illness/psychology , Critical Illness/therapy , Humans , Qualitative Research , Survivors/psychologyABSTRACT
The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States. DESIGN: Cross-sectional survey. SETTING: Thirty-nine RCs, representing a combined 156 hospitals within 29 health systems participated. PATIENTS: None. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: RC demographics, referral criteria, and operating characteristics were collected, including measures used to assess physical, psychologic, and cognitive recoveries. Thirty-nine RC surveys were completed (94% response rate). ICU-RC teams included physicians, pharmacists, social workers, physical therapists, and advanced practice providers. Funding sources for ICU-RCs included clinical billing (n = 20, 77%), volunteer staff support (n = 15, 58%), institutional staff/space support (n = 13, 46%), and grant or foundation funding (n = 3, 12%). Forty-six percent of RCs report patient visit durations of 1 hour or longer. ICU-RC teams reported use of validated scales to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%; physical, 69%; and cognitive, 46%). CONCLUSIONS: Operating structures of RCs vary, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. ICU- and COVID-RCs in the United States employ varied funding sources and endorse different assessment measures during visits to guide care coordination. Common features include integration of ICU clinicians, interdisciplinary approach, and focus on severe critical illness. The heterogeneity in RC structures and processes contributes to future research on the optimal structure and process to achieve the best postintensive care syndrome and postacute sequelae of COVID outcomes.
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OBJECTIVES: Investigate the challenges experienced by survivors of critical illness and their caregivers across the transitions of care from intensive care to community, and the potential problem-solving strategies used to navigate these challenges. DESIGN: Qualitative design-data generation via interviews and data analysis via the framework analysis method. SETTING: Patients and caregivers from three continents, identified through the Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS: Patients and caregivers following critical illness. INTERVENTIONS: Nil. MEASUREMENTS AND MAIN RESULTS: From 86 interviews (66 patients, 20 caregivers), we identified the following major themes: 1) Challenges for patients-interacting with the health system and gaps in care; managing others' expectations of illness and recovery. 2) Challenges for caregivers-health system shortfalls and inadequate communication; lack of support for caregivers. 3) Patient and caregiver-driven problem solving across the transitions of care-personal attributes, resources, and initiative; receiving support and helping others; and acceptance. CONCLUSIONS: Survivors and caregivers experienced a range of challenges across the transitions of care. There were distinct and contrasting themes related to the caregiver experience. Survivors and caregivers used comparable problem-solving strategies to navigate the challenges encountered across the transitions of care.
Subject(s)
Caregivers/psychology , Continuity of Patient Care , Critical Care/psychology , Critical Illness/psychology , Critical Illness/rehabilitation , Survivors/psychology , Adaptation, Psychological , Attitude to Health , Follow-Up Studies , HumansABSTRACT
BACKGROUND: After critical illness, patients are often left with impairments in physical, social, emotional, and cognitive functioning. Peer support interventions have been implemented internationally to ameliorate these issues. OBJECTIVE: To explore what patients believed to be the key mechanisms of effectiveness of peer support programs implemented during critical care recovery. METHODS: In a secondary analysis of an international qualitative data set, 66 telephone interviews with patients were undertaken across 14 sites in Australia, the United Kingdom, and the United States to understand the effect of peer support during recovery from critical illness. Prevalent themes were documented with framework analysis. RESULTS: Most patients who had been involved in peer support programs reported benefit. Patients described 3 primary mechanisms: (1) sharing experiences, (2) care debriefing, and (3) altruism. CONCLUSION: Peer support is a relatively simple intervention that could be implemented to support patients during recovery from critical illness. However, more research is required into how these programs can be implemented in a safe and sustainable way in clinical practice.
Subject(s)
Altruism , Peer Group , Social Support , Survivors , Australia , Critical Illness , Humans , Intensive Care Units , Qualitative Research , United Kingdom , United StatesABSTRACT
To understand from the perspective of patients who did, and did not attend ICU recovery programs, what were the most important components of successful programs and how should they be organized. DESIGN: International, qualitative study. SETTING: Fourteen hospitals in the United States, United Kingdom, and Australia. PATIENTS: We conducted 66 semi-structured interviews with a diverse group of patients, 52 of whom had used an ICU recovery program and 14 whom had not. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using content analysis, prevalent themes were documented to understand what improved their outcomes. Contrasting quotes from patients who had not received certain aspects of care were used to identify perceived differential effectiveness. Successful ICU recovery programs had five key components: 1) Continuity of care; 2) Improving symptom status; 3) Normalization and expectation management; 4) Internal and external validation of progress; and 5) Reducing feelings of guilt and helplessness. The delivery of care which achieved these goals was facilitated by early involvement (even before hospital discharge), direct involvement of ICU staff, and a focus on integration across traditional disease, symptom, and social welfare needs. CONCLUSIONS: In this multicenter study, conducted across three continents, patients identified specific and reproducible modes of benefit derived from ICU recovery programs, which could be the target of future intervention refinement.
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OBJECTIVES: Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them. DESIGN: Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data. SETTING: Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents. SUBJECTS: Clinicians from 21 sites. MEASUREMENT AND MAIN RESULTS: Ten enablers and nine barriers to implementation of "ICU follow-up clinics" were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of "peer support groups" were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising. CONCLUSIONS: Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.
Subject(s)
Critical Illness , Intensive Care Units , Outpatient Clinics, Hospital/organization & administration , Self-Help Groups/organization & administration , Survivors/psychology , Adult , Health Services Accessibility/organization & administration , Humans , Middle Aged , Outpatient Clinics, Hospital/economics , Peer Group , Qualitative Research , Self-Help Groups/economicsABSTRACT
OBJECTIVE: To identify the key mechanisms that clinicians perceive improve care in the intensive care unit (ICU), as a result of their involvement in post-ICU programs. METHODS: Qualitative inquiry via focus groups and interviews with members of the Society of Critical Care Medicine's THRIVE collaborative sites (follow-up clinics and peer support). Framework analysis was used to synthesize and interpret the data. RESULTS: Five key mechanisms were identified as drivers of improvement back into the ICU: (1) identifying otherwise unseen targets for ICU quality improvement or education programs-new ideas for quality improvement were generated and greater attention paid to detail in clinical care. (2) Creating a new role for survivors in the ICU-former patients and family members adopted an advocacy or peer volunteer role. (3) Inviting critical care providers to the post-ICU program to educate, sensitize, and motivate them-clinician peers and trainees were invited to attend as a helpful learning strategy to gain insights into post-ICU care requirements. (4) Changing clinician's own understanding of patient experience-there appeared to be a direct individual benefit from working in post-ICU programs. (5) Improving morale and meaningfulness of ICU work-this was achieved by closing the feedback loop to ICU clinicians regarding patient and family outcomes. CONCLUSIONS: The follow-up of patients and families in post-ICU care settings is perceived to improve care within the ICU via five key mechanisms. Further research is required in this novel area.
Subject(s)
Critical Care/organization & administration , Intensive Care Units/organization & administration , Patient Satisfaction , Quality Improvement/organization & administration , Subacute Care/organization & administration , Adult , Attitude of Health Personnel , Critical Care/standards , Family/psychology , Feedback , Female , Humans , Intensive Care Units/standards , Interviews as Topic , Male , Middle Aged , Qualitative Research , Subacute Care/standards , Survivors/psychologyABSTRACT
When nurses integrate patient expertise, nurse-to-nurse handoff becomes patient-centered (nurse and patient), and the weak link between quality and safety is mitigated. The existing paradigm for handoff is an ineffective measure to minimize errors. This article describes a reimagined bedside handoff-transitioning handoff from its prescriptive nurse-centered interaction to a patient-centered partnership using the principles of complex adaptive systems, simple rules, and partnerships that address the uniqueness of each patient and nurse interaction.
Subject(s)
Patient Handoff/organization & administration , Patient Safety , Patient Satisfaction , Patient-Centered Care/methods , Communication , Continuity of Patient Care , HumansABSTRACT
Acute pericarditis occurs most frequently after a viral attack. Other causes are autoimmune conditions, infection, chest trauma, cardiac surgery, or cardiac procedure. The presenting symptom is retrosternal chest pain. A pericardial rub is characteristic. Diffuse upward sloping ST segments are found with electrocardiogram. Pericardial effusions may be demonstrated with an echocardiogram. High-dose nonsteroidal antiinflammatory medications are the primary treatment. Adding colchicine reduces recurrence. It responds well to pharmacologic therapy within 1 to 2 weeks. Monitoring for complications is essential. The most serious complication is cardiac tamponade. For this, prompt diagnosis and treatment can be life-saving.
Subject(s)
Acute Disease , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Pericarditis/complications , Pericarditis/drug therapy , Cardiac Tamponade/diagnosis , Cardiac Tamponade/etiology , Cardiac Tamponade/therapy , Chest Pain/etiology , Electrocardiography , Humans , Magnetic Resonance Imaging , Pericarditis/diagnosisABSTRACT
BACKGROUND: Cardiac tamponade is difficult to diagnose. Patients often experience sustained distress. Mood changes in the early stages of cardiac tamponade were previously described. However, precise descriptions of these moods have not been reported. OBJECTIVE: We sought to describe the mood changes specifically referred to as dysphoria in the patients' own words. METHODS: Structured and semistructured interviews were performed with 29 patients who had survived cardiac tamponade. RESULTS: Twenty-six patients (89.6%) affirmed some dysphoric mood. "A bad thing is happening" was most frequently affirmed. "Felt anxious," "could not stay still," and "difficult to settle down" followed. Answers to open-ended questions and free comments were categorized into "fear," "anxiety," "impending doom," "ill feeling," "unusual," "uncertain," "depressed," and "discouraged." CONCLUSION: The majority of patients surviving cardiac tamponade experienced a dysphoric mood. Mood changes may provide a reliable indicator for those at risk for cardiac tamponade.
Subject(s)
Affect , Cardiac Tamponade/complications , Depressive Disorder, Major/psychology , Perception , Stress, Psychological/complications , Cardiac Tamponade/drug therapy , Cardiac Tamponade/psychology , Depressive Disorder, Major/etiology , Female , Health Status Indicators , Humans , Interview, Psychological , Male , Middle Aged , Psychometrics , Qualitative Research , Risk Assessment/methods , Stress, Psychological/psychologyABSTRACT
Obese patients in the ICU present unique challenges to the health care team and specific challenges to nurses. This article reviews the science and art of resource use for obese patients in the ICU. Staff nurses and advanced practice nurses can make important contributions in evaluating optimal resource use and improving outcomes in this population of vulnerable patients.
Subject(s)
Critical Illness/nursing , Obesity/nursing , Health Resources/statistics & numerical data , Humans , Nursing/methods , Obesity/complications , Treatment OutcomeABSTRACT
The purpose of this research was to determine the effect of a Family-Maintained Progress Journal on the anxiety of the family member of patients undergoing coronary artery bypass graft surgery. Ninety-one family members were assigned to either the group receiving the usual information or the group that also received a diary. Anxiety was significantly lower after 3 days although the reduction was not different by group. Trait anxiety had the most influence on anxiety reduction, followed by uncertainty. Content analysis revealed negative emotions with illness appearance of the patient, requests for regular communication, and concerns about reducing pain. Family members wrote that faith in God and support of others helped them. Nurses can affect uncertainty by adjusting the information provided according to family preferences and by supporting their faith practices. Further research on the role of faith in uncertainty and anxiety during critical illness is needed.