Bereavement in critical care: A narrative review and practice exploration of current provision of support services and future challenges

© The Intensive Care Society 2020. This is the accepted manuscript version of an article which has been published in final form at https://doi.org/10.1177%2F1751143720928898This special article outlines the background to bereavement in critical care and scopes the current provision and evidence for bereavement support following death in critical care. Co-authored by a family member and former critical care patient, we aim to draw out the current challenges and think about how and where support can be implemented along the bereavement pathway. We draw on the literature to examine different trajectories of dying in critical care and explore how these might impact bereavement, highlighting important points and risk factors for complicated grief. We present graphic representation of the critical junctures for bereavement in critical care. Adjustment disorders around grief are explored and the consequences for families, including the existing evidence base. Finally, we propose new areas for research in this field.Peer reviewedFinal Accepted Versio

Nurse Driven Early Mobility in the Intensive Care Unit: Mobility Protocol and a Designated Mobility Champion

Decreased mobility in hospitalized patients can lead to various health consequences, including increased morbidity and mortality. In the Intensive Care Unit (ICU), patients are not mobilized as frequently or as often as possible. Barriers to mobilization include limited resources such as time and staffing, perceived risk, and insufficient training in safe patient handling. This quality improvement initiative aimed to increase out-of-bed mobility in ICU patients, address activity orders at interdisciplinary rounds, and trial a designated mobility champion. The America Association of Critical-Care Nurses (AACN) Early Progressive Mobility (EPM) protocol and Bedside Mobility Assessment Tool (BMAT) were adopted and used to discuss patients’ mobility during interdisciplinary rounds. During these rounds, a mobility champion who received additional training from physical therapy in safe patient handling attended these rounds. The mobility champion then coordinated with nursing staff and other care team members throughout the day to mobilize patients. Increased numbers of patients with COVID-19 did not fit the eligibility criteria during the implementation period, and increased mobility was not seen. However, the ICU team members felt the interventions, especially the use of a mobility champion, were beneficial and decided to extend the new practice for continuing review. The mobility champion is now utilized on all inpatient units. All inpatient units have seen an increase in patients mobilized. Nurse-driven early mobility tools are safe and feasible and give nurses greater autonomy in planning mobility interventions. The use of a dedicated mobility champion compliments these tools and helps reduce barriers to early mobilization.https://scholar.rochesterregional.org/nursingresearchday/1019/thumbnail.jp

Funding intensive care - approaches in systems using diagnosis-related groups.

This report reviews approaches to funding intensive care in health systems that use activitybased payment mechanisms based on diagnosis-related groups (DRGs) to reimburse hospital care. The report aims to inform the current debate about options for funding intensive care services for adults, children and newborns in England. Funding mechanisms reviewed here include those in Australia (Victoria), Denmark, France, Germany, Italy, Spain, Sweden and the United States (Medicare). Approaches to organising, providing and funding hospital care vary widely among these countries/states, largely reflecting structural differences in the organisation of healthcare systems. Mechanisms of funding intensive care services tend to fall into three broad categories: • those that fund intensive care through DRGs as part of one episode of hospital care only (US Medicare, Germany, selected regions in Sweden and Italy) • those that use DRGs in combination with co-payments (Victoria, France) • those that exclude intensive care from DRG funding and use an alternative form of payment, for example global budgets (Spain) or per diems (South Australia). Approaches to funding paediatric and neonatal intensive care largely reflect the overall funding mechanism for intensive care. Evidence reviewed here indicates a general concern of potential underfunding of intensive care. These problems may be particularly pertinent for those settings that provide neonatal and paediatric care because of the very high costs and the relatively smaller number of cases in these settings compared with adult intensive care. Similar issues apply to highly specialised services in adult intensive care, such as treatment of severe burns. Given the variety of approaches to funding intensive care services, this review suggests that there is no obvious example of “best practice” or dominant approach used by a majority of systems. Each approach has advantages and disadvantages, particularly in relation to the financial risk involved in providing intensive care. While the risk of underfunding intensive care may be highest in systems that apply DRGs to the entire episode of hospital care, including intensive care, concerns about potential underfunding were voiced in all systems reviewed here. Arrangements for additional funding in the form of co-payments or surcharges may reduce the risk of underfunding. However, these approaches also face the difficulty of determining the appropriate level of (additional) payment and balancing the incentive effect arising from higher payment

Anaesthesia and Intensive Care

The anaesthetist has seen his role steadily expand and it is hard to think of one medical specialty in which anaesthetists are not involved at least to some extent. We present a range of papers which demonstrates the breadth of anaesthesia: from its traditional realm in the operating theatre to critical care and resuscitation onto chronic pain and obstetric analgesia.peer-reviewe

Metabonomics and Intensive Care

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency medicine 2016. Other selected articles can be found online at http://www.biomedcentral.com/collections/annualupdate2016. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901

Predicting death and readmission after intensive care discharge

Background: Despite initial recovery from critical illness, many patients deteriorate after discharge from the intensive care unit (ICU). We examined prospectively collected data in an attempt to identify patients at risk of readmission or death after intensive care discharge. Methods: This was a secondary analysis of clinical audit data from patients discharged alive from a mixed medical and surgical (non-cardiac) ICU. Results: Four hundred and seventy-five patients (11.2%) died in hospital after discharge from the ICU. Increasing age, time in hospital before intensive care admission, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and discharge Therapeutic Intervention Scoring System (TISS) score were independent risk factors for death after intensive care discharge. Three hundred and eighty-five patients (8.8%) were readmitted to intensive care during the same hospital admission. Increasing age, time in hospital before intensive care, APACHE II score, and discharge to a high dependency unit were independent risk factors for readmission. One hundred and forty-three patients (3.3%) were readmitted within 48 h of intensive care discharge. APACHE II scores and discharge to a high dependency or other ICU were independent risk factors for early readmission. The overall discriminant ability of our models was moderate with only marginal benefit over the APACHE II scores alone. Conclusions: We identified risk factors associated with death and readmission to intensive care. It was not possible to produce a definitive model based on these risk factors for predicting death or readmission in an individual patient.Not peer reviewedAuthor versio

ACCCN Workforce Standards for Intensive Care Nursing: Systematic and evidence review, development, and appraisal

Background: The intensive care nursing workforce plays an essential role in the achievement of positive healthcare outcomes. A growing body of evidence indicates that inadequate nurse staffing and poor skill mix are associated with negative outcomes for patients, and potentially compromises nurses’ ability to maintain the safety of those in their care. In Australia, the Australian College of Critical Care Nurses (ACCCN) has previously published a position statement on intensive care staffing. There was a need for a stronger more evidence based document to support the intensive nursing workforce. Objectives: To undertake a systematic and evidence review of the evidence related to intensive care nurse staffing and quality of care, and determine evidence-based professional standards for the intensive care nursing workforce in Australia. Methods: The National Health and Medical Research Council standard for clinical practice guidelines methodology was employed. The English language literature, for the years 2000-2015 was searched. Draft standards were developed and then peer- and consumer-reviewed. Results: A total of 553 articles was retrieved from the initial searches. Following evaluation, 231 articles met the inclusion criteria and were assessed for quality using established criteria. This evidence was used as the basis for the development of ten workforce standards, and to establish the overall level of evidence in support of each standard. All draft standards and their subsections were supported multi-professionally (median score >6) and by consumers (85–100% agreement). Following minor revisions, independent appraisal using the AGREE II tool indicated that the standards were developed with a high degree of rigour. Conclusion: The ACCCN intensive care nursing nurse workforce standards are the first to be developed using a robust, evidence-based process. The standards represent the optimal nurse workforce to achieve the best patient outcomes and to maintain a sustainable intensive care nursing workforce for Australia

Mortality and quality of life in the five years after severe sepsis

Peer reviewedPublisher PD

Psychiatric nurses’ views on criteria for psychiatric intensive care: acute and intensive care staff compared

Aim: To explore and investigate differences between the views of qualified nurses working in psychiatric intensive care units (PICUs) and acute care wards on which patients are appropriate for PICU care. Background: Previous research on the area of psychiatric intensive care highlights the great differences that exist in all aspects of service provision, from unit size and staffing levels to treatment approaches and physical environment. One of the most common areas of controversy is the type of client behaviour that warrants admission to the PICU. Method: Structured interviews of 100 qualified nursing staff (in the London area, England) working on either acute or PICU wards were used to gather data on appropriate and inappropriate referral to PICUs. Comments made during the course of the interviews were also collected and subjected to content analysis. Findings: There was evidence to support the hypothesis that acute ward staff considered patients suitable for PICU care at a lower level of risk than PICU staff thought appropriate. In comparison to acute ward nurses, those working in PICUs attended to a broader range of factors when considering suitability for admission to PICU. Appropriate reasons for transfer fell into five groups: risk to others; risk of intentional harm to self; risk of unintentional harm to self; therapeutic benefit from the PICU environment; and legitimate acute ward care problem. Inappropriate reasons for transfer fell into four groups: low risk to others and/or self; illegitimate acute admission care problems; patient belongs elsewhere; policy issues. Conclusion: The study opens up a range of issues not previously studied in relation to the use of PICUs and the intricate relationship of this use with the available acute care wards and other services. These findings and their implications for the care of acute and disturbed psychiatric patients are discussed

Sleeping on a problem: the impact of sleep disturbance on intensive care patients - a clinical review

Sleep disturbance is commonly encountered amongst intensive care patients and has significant psychophysiological effects, which protract recovery and increases mortality. Bio-physiological monitoring of intensive care patients reveal alterations in sleep architecture, with reduced sleep quality and continuity. The etiological causes of sleep disturbance are considered to be multifactorial, although environmental stressors namely, noise, light and clinical care interactions have been frequently cited in both subjective and objective studies. As a result, interventions are targeted towards modifiable factors to ameliorate their impact. This paper reviews normal sleep physiology and the impact that sleep disturbance has on patient psychophysiological recovery, and the contribution that the clinical environment has on intensive care patients' sleep