Nursing & Allied Health Professionals – Post ICU Care: Impact & consequences (Abstracts)

Dealing with the aftermath of critical illness – the ENSURE (ENabling and SUpporting REcovery) intensive care follow up clinic

(Andrew Lockwood)

ICU survivors face long journey beyond hospital discharge

Adoption of InS:PIRE (Glasgow) post-ICU rehab model, incorporating needs of patient and family

  • Included: age >18, ICU stay >4d, self-referral or GP referral, pts from other ICUs living in catchment area
  • Engage primary care team (GPs on average see 1 ICU survivor per year)

 

5 week MDT approach

  • Off site location: parking, refreshments, no associations with hospital
  • checklist for concerns sent prior to identify issues and identify best MDT member to handle
  • weekly session for pt, also Carer session away from ICU survivor
  • Key strength: pt volunteers (previous ICU survivors)
  • Consultant and Psychologist meet with pt 2 out of 5 weeks to cover complex medical and psychological needs

Of note:

  1. Outcome measure score (including personal health rating, control of life etc) to ensure this follow up is adding value –> No drop-off in the score up to 1 year after the first follow-up meeting
  2. Follow-up team able to make direct onward referrals for further specialist input without going via GP
  3. Anecdotal report of pt benefiting greatly from visiting ICU bedspace – nightmares and flashbacks dissipated quickly after this
  4. Important to realise that ICU pts who were not sedated / ventilated can still develop psychological challenges during recovery
  5. Major stressor found not to be ICU admission but ICU discharge to ward –> will lead on to develop study morning for ward staff regarding post-ICU care
  6. Quarterly newsletter for ICU staff to feedback learning points, verbal messages passed to any named ward staff
  7. Noise issue – Noise Ears now installed to monitor and analyse noise levels, address accordingly
  8. Pt diaries previously for long-stayers, but all pts can benefit from diary
  9. Carer session – Carer Strain Index done on first meeting, but limited intervention as carer is not the pt

 

How does healthcare quality influence Care Left Undone in neonatal and paediatric intensive care units?

(Silvia Rossi)

Care Left Undone (CLU) phenomenon gained interest within the past decade – understanding this can contribute to quality improvement

Aim: Investigate which nursing staff and work environment variables could influence the prevalence of CLU in NICUs and PICUs

13 Hospitals: 3 Paediatric free-standing hospitals, 10 General hospitals, 169 Units

13 types of CLU (activity omitted on the nurse’s most recent shift)

Variables considered: Work environment (PES-NWI), Depersonalisation (MBI), Emotional exhaustion (MBI), Intention-to-leave, Quality of Healthcare

6 categories of care activities most at risk of becoming CLU:

  • adequate pt surveillance
  • pain management
  • educating pt and family
  • adequately documenting nursing care
  • planning care
  • frequent changing of pt position

 

Variables that could Increase the risk of omission:

  • Depersonalisation — Oral hygiene (OR=1.065; 95%CI=1.012-1.120)
  • Emotional exhaustion — Develop or update nursing care plans (OR=1.029; 95%CI=1.009-1.050)
  • Intention to leave job (within 1 year) — Prepare pts and families for discharge (OR=1.983, 95%CI=1.243-3.164)

Variables that could Reduce the risk of omission:

  • Good work environment — Develop or update nursing care plans (OR=0.152; 95%CI=0.342-0.768)

NOT taken into account: nursing workload, severity of illness, nurse-pt ratio

Conclusion:

Nurses miss some activities in presence of personal conditions and Environmental conditions including Organisational culture and Unit behaviour

Need to consider the CLU phenomenon in its Entirety

 

Effect of nurse led follow-up consultations to improve Sense of Coherence in patients discharged after intensive care treatment

(Ase Valso)

Pts with delusional and frightening ICU memories have increased risk for Post-traumatic stress (PTS) symptoms –> Constructing an illness narrative to make sense of ICU experiences important for psychological recovery

Sense of Coherence (SOC) reflects ability to cope with stress

  • Comprehensibility: make sense of adversity
  • Manageability: resources to meet challenges
  • Meaningfulness: challenges worth engagement

Included: >18 yo, ICU stay >24hrs

PTS score done shortly post-d/c from ICU – pts with higher scores (>25) randomised:

Standard care (control) or

Nurse-led follow up consultation (Intervention)

  • 1 meeting shortly after d/c (45-60mins), 1 or 2 further meetings (phone or in-person on ward)
  • Structured guide based on trauma focused CBT – aiming to give patient an improved Sense of Coherence, not psychological therapy (intervention nurse is experienced and familiar with ICU care, given 2d training but not experienced in psychology or psychiatry)

Of note:

  1. pts in intervention group scored highly in the SOC score, and nurse-led intervention did not significantly increase SOC compared to control group
  2. No obvious difference in outcome whether follow up was done by phone or in-person
  3. Criticism by author : existing belief is that early intervention to restore SOC may prevent onset of post-traumatic stress, but this study may have been carried out too early with sick patients; duration of intervention period may have been too short to detect any difference

 

Pain occurrence and associated factors after discharge from the intensive care unit to the hospital ward

(Kirsti Toien)

Same pt cohort as prevented in previous abstract on SOC and Nurse-led intervention

Pain is a serious and challenging problem for ICU pts, impacting on respiration, mobilisation and rehabilitation

  • pain management is important part of ICU care
  • focus and research is lacking on pain-related issues post-ICU discharge

 

Aim: To investigate pain intensity and interference with daily activity in pts immediately after ICU discharge, and to explore possible variables associated with worst pain and pain interference among demographic and clinical variables

Results (pain location) n=469

Abdomen  202 (43%); Lower back 132 (28%); Shoulder / forearm 102 (22%); Chest 82 (18%); Neck 76 (16%); Pelvis 71 (15%); Knee 70 (15%)

 

Physical and Psychological Outcomes of patients discharged from a rehab-active Critical Care Unit in the United Kingdom

(Fiona Howroyd)

Post-intensive Care syndrome (PICS):

  • physical (e.g. weakness, pain)
  • functional
  • psychosocial (e.g. anxiety, depression)
  • cognitive (memory impairment)

Aim: To identify levels of anxiety, depression, psychological stress and mobility, and to explore the impact of mobility levels upon psychological outcomes

Data collection over 3 months

Outcomes:

  • Hospital Anxiety Depression Scale (HADS)
  • Intensive Care Psychological Assessment Tool e.g. hallucinations, flashbacks, sleep problems (IPAT)
  • Manchester Mobility Scale (MMS)

Conclusions:

  1. High prevalence of psychological morbidity
  2. Increased mobility associated with less anxiety
  3. Increased mobility associated with shorter length of stay on ward

Of note: Structured ward follow up including physiotherapist, nurse and psychological support

Mobile pts can still have PICS and should be supported as required