June 3, 2019

Raising awareness of the issue of acute stress

Final results of POPPI (Psychological Outcomes following a nurse-led Preventive Psychological Intervention for critically ill patients)


Initial results from the POPPI (Psychological Outcomes following a nurse-led Preventive Psychological Intervention for critically ill patients) study were presented at ESICM LIVES in Paris in October 2018. Now, the final results of the study are available and have been published in the JAMA (the Journal of the American Medical Association).

The study, led by Professor Kathy Rowan, Intensive Care National Audit & Research Centre, London, UK, concluded that among critically ill patients in the ICU, a nurse-led preventive, complex psychological intervention did not significantly reduce patient-reported Post-Traumatic Stress Disorder (PTSD) symptom severity at 6 months. Rowan and colleagues thus conclude that their findings do not support the use of this psychological intervention.

In the video that accompanies this article, recorded during ESICM LIVES 2018 in Paris, Professor Rowan explains the rationale behind the POPPI study.

PTSD has always been an issue for patients that have been treated in intensive care. Among patients admitted to the Intensive Care Unit (ICU), a meta-analysis of outcomes for survivors, during the first six months after ICU discharge, indicated a pooled prevalence for clinically important Post Traumatic Stress Disorder (PTSD) symptoms of 25%.

Acute stress while in the ICU (see here and here) and early memories of frightening ICU experiences (e.g., hallucinations, paranoid delusions, and nightmares) have been identified as independent risk factors for longer-term psychological morbidity, including PTSD symptom severity.

“Evidence suggests that addressing these risk factors early, commencing while in the ICU, might prevent longer-term consequences and that addressing such factors after discharge may be too late. Research on ICU patients with trauma indicated fewer experienced PTSD symptoms if they were seen by clinical psychologists while in the ICU,” explains Professor Rowan.

However, the reality of the UK’s National Health Service (NHS) — which has been under intense financial pressure for many years especially during the last decade of the Conservative-led government — is that very few UK NHS ICUs have regular, if any, access to psychologists.

“Since there is evidence indicating that non-experts can be trained to deliver effective psychological interventions, we decided to train ICU nurses to deliver a preventive, complex psychological intervention,” explains Professor Rowan. “The use of such non-specialists could be cost-effective.”

The POPPI team conducted a multi-centre, parallel-group, cluster-randomised clinical trial with integrated economic and process evaluations in 24 ICUs in the United Kingdom. Participants were critically ill patients who regained mental capacity following receipt of level 3 (intensive) care.

A total of 2,961 eligible patients were identified from September 2015 to January 2017. A total of 2,048 were approached for participation in the ICU, of which 1,458 provided informed consent. Follow-up was completed in December 2017.

A total of 24 ICUs were randomised 1:1 to the intervention or control group. Intervention ICUs (n = 12; 669 participants) delivered usual care during a baseline period followed by an intervention period.

The preventive, complex psychological intervention comprised promotion of a therapeutic ICU environment plus three stress support sessions and a relaxation and recovery programme delivered by trained ICU nurses to high-risk (acutely stressed) patients. Control ICUs (n = 12; 789 participants) delivered usual care in both baseline and intervention periods.

The primary clinical outcome was PTSD symptom severity among survivors at six months, measured using the PTSD Symptom Scale–Self-Report questionnaire. Among 1,458 enrolled patients (mean age 58 years; 599 women [41%]), 1,353 (93%) completed the study and were included in the final analysis.

At six months, the mean PTSD Symptom Scale–Self-Report questionnaire score in intervention ICUs was 11.8 (baseline period) compared with 11.5 (intervention period) (difference −0.40) and in control ICUs, 10.1 (baseline period) compared with 10.2 (intervention period) (difference 0.06) between periods. There was no significant difference in PTSD symptom severity at six months (treatment effect estimate of −0.03; P = 0.98).



The research team propose several reasons why the intervention may not have worked. The sessions may have been delivered too early for the patients to process them properly.

Some patients only received two sessions instead of three, often because they were discharged before the third session. And, despite the non-expert nurses being confident they could deliver the intervention during training, it is possible they found it difficult when dealing with patients with complex needs.

The authors acknowledge that interventions such as these may need to be delivered by specialist psychologists.



Professor Rowan concludes: “Among critically ill patients in the ICU, a nurse-led preventive, complex psychological intervention did not significantly reduce patient-reported PTSD symptom severity at six months. These findings do not support the use of this psychological intervention.”

This article was submitted by Tony Kirby, on behalf of ESICM.


1) Dorothy M. Wade, PhDPaul R. Mouncey, MScAlvin Richards-Belle, BScJerome Wulff, PhDDavid A. Harrison, PhD et al., Effect of a Nurse-Led Preventive Psychological Intervention on Symptoms of Posttraumatic Stress Disorder Among Critically Ill Patients: a randomized clinical trial, JAMA 2019;321(7):665-675.




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