Improving Quality of Life in Patients at Risk for Post-Intensive Care Syndrome.

OBJECTIVE: To improve quality of life (QOL) in patients at risk for post-intensive care syndrome (PICS). PATIENTS AND METHODS: We conducted a mixed-method, prospective, observational, pre-post interventional study in an adult medical and mixed medical/surgical/transplant intensive care unit (ICU) at a tertiary academic hospital. Preintervention included patients admitted from October 1 through October 31, 2016, and postintervention included patients admitted from January 15 through February 14, 2017. First, a multidisciplinary team of stakeholders identified barriers associated with decreased QOL in patients at risk for PICS. Next, interventions were designed and implemented. The effect of interventions was assessed using a mixed-method analysis. The qualitative analysis used a modified grounded theory approach. The quantitative analysis included assessment of preexisting symptoms and risk factors associated with PICS. The 36-Item Short-Form Health Status Survey (SF-36), which surveys physical and mental composite scores, was used to assess QOL. RESULTS: Barriers identified were lack of awareness and understanding of PICS. Interventions included educational videos, paper and online education and treatment materials, and online and in-person support groups for education and treatment. After interventions, the qualitative analysis found that patients who participated in the interventions after hospital discharge showed improved QOL, whereas education during hospitalization alone was not effective. The quantitative analysis did not find improvement in QOL, as defined by SF-36 physical or mental composite scores. CONCLUSION: Interventions targeted to patients after hospitalization may offer subjective improvement in QOL for those at risk for PICS.

Patients who complete advance directives and what they prefer.

OBJECTIVE: To determine health care preferences expressed by patients in advance directives (ADs) and to identify characteristics of patients who completed them. PATIENTS AND METHODS: A computer-generated random sample of 500 patients was selected from the 25,865 (margin of error, +/- 4.34%) unique patients who submitted ADs to Mayo Clinic Rochester between January 1, 2004, and July 1, 2005. After excluding 24 (4.8%) patients who had submitted documents related to financial and property matters instead of ADs, we analyzed the contents of the 476 ADs and the demographic features of the patients to whom the documents belonged. RESULTS: The median (range) age of the patients at the time they signed their respective ADs was 67 (19-97) years. Of the 476 study patients, 409 (91.3%) were high school graduates; 339 (71.2%) had submitted a combined AD, which has features of a living will and a health care power of attorney; 434 (91.2%) had designated a health care agent; and most had granted the agent powers to consent for procedures (340 [78.3%]), to access information (327 [75.3%]), and to withhold and withdraw life-sustaining treatments (337 [77.6%]). Most patients expressed a desire for pain control (308 [64.7%]). For the clinical situations of dying or permanent unconsciousness, most patients explicitly expressed a preference to avoid "general life support" (371 [77.9%]) but did not explicitly address common life-sustaining treatments, including cardiopulmonary resuscitation, mechanical ventilation, hemodialysis, blood transfusion, and artificial nutrition and hydration (if they did, nearly all expressed a preference to avoid the treatments). CONCLUSION: In ADs submitted to our institution, most patients designated a health care agent and granted the agent broad decision-making powers. Although most expressed a desire to avoid "general life support" if dying or permanently unconscious, few expressed preferences regarding specific life-sustaining treatments. Patients, clinicians, and others who use ADs, and investigators contemplating research involving ADs, might find these results informative.

Preliminary noise reduction efforts in a medical intensive care unit.

Noise is a significant contributor to sleep disruption in the intensive care unit (ICU) that may result in increased patient morbidity such as delirium and prolonged length of stay in ICU. We conducted a pre-post intervention study in a 24-bed tertiary care academic medical ICU to reduce the mean noise levels. Baseline dosimeter recordings of ICU noise levels demonstrated a mean noise level of 54.2 A-weighted decibels (dBA) and peak noise levels of 109.9 dBA, well above the Environmental Protection Agency's recommended levels. There were 1735 episodes of "defects" (maximum noise levels > 60 dBA). Following implementation of multipronged interventions, although the mean noise levels did not change significantly between pre- and post-intervention (54.2 vs 53.8 dBA; p = 0.96), there was a significant reduction in the number of "defects" post-intervention (1735 vs 1289, p ≤ 0.000), and the providers felt that the patients were sleeping longer in the ICU post-intervention.