The Psychological Impact of Admission to Intensive Care

This thesis illustrates the contribution of clinical psychology to the conceptualisation, measurement and mitigation of distress in families and staff, in the acute setting of intensive care. It examines, with reference to five separate papers, the extent and nature of the distress experienced by children and their parents in the year following discharge; the trajectory of recovery in quality of life in patient survivors and the impact of two forms of intervention - a) the provision of a follow up clinic appointment and b)Narrative Exposure Therapy - on parents’ psychological symptoms. The experience of intensive care staff is then described, drawing on the findings of two further papers which focus on the phenomenon of ‘burnout’ as well as examining traumatic and morally distressing aspects of this work. Aspects of experience unique to the children included early distress related to the impact of hallucinations and later on having to cope with the continuing impact of critical illness on their quality of life. Parents were troubled by the fear of loss and having to assimilate large amounts of important medical information in an emotionally demanding situation. Staff reported significant levels of emotional exhaustion and post-traumatic stress reactions. They also identified a number of aspects of their work as giving rise to moral distress, particularly in relation to treating patients with a poor prognosis. This synthesis demonstrates the value of examining different perspectives and the importance of measurement. It also highlights the potential role of a psychologist in intervention, both at the individual clinical level and at the organisational level, in a clinic and as part of the team. Finally examples are provided of the contribution this work has made to international outcomes research and to the current pressing debate on the assessment of distress in staff in this challenging setting

Conceptualizing post intensive care syndrome in children: the PICS-p Framework*

Context: Over the past several decades, advances in pediatric critical care have saved many lives. As such, contemporary care has broadened its focus to also include minimizing morbidity. Post Intensive Care Syndrome, also known as “PICS,” is a group of cognitive, physical, and mental health impairments that commonly occur in patients after ICU discharge. Post Intensive Care Syndrome has been well-conceptualized in the adult population but not in children. Objective: To develop a conceptual framework describing Post Intensive Care Syndrome in pediatrics that includes aspects of the experience that are unique to children and their families. Data Synthesis: The Post Intensive Care Syndrome in pediatrics (PICS-p) framework highlights the importance of baseline status, organ system maturation, psychosocial development, the interdependence of family, and trajectories of health recovery that can potentially impact a child’s life for decades. Conclusion: Post Intensive Care Syndrome in pediatrics will help illuminate the phenomena of surviving childhood critical illness and guide outcomes measurement in the field. Empirical studies are now required to validate and refine this framework, and to subsequently develop a set of core outcomes for this population. With explication of Post Intensive Care Syndrome in pediatrics, the discipline of pediatric critical care will then be in a stronger position to map out recovery after pediatric critical illness and to evaluate interventions designed to mitigate risk for poor outcomes with the goal of optimizing child and family health

Screening for factors influencing parental psychological vulnerability during a child’s PICU admission

OBJECTIVES: To identify the risks of developing post-traumatic stress disorder (PTSD) and/or depression in parents following their child’s PICU admission using a brief screening instrument and to examine the associations with these risks.  DESIGN: A cross-sectional parental survey.  SETTING: A general 13-bed PICU at a large teaching hospital.  SUBJECTS: One hundred and seven parents of 75 children admitted to the PICU.    INTERVENTIONS: None.  MEASUREMENTS AND MAIN RESULTS: All parents completed the 10-item Posttraumatic Adjustment Screen (PAS) before discharge. The PAS assesses risk factors known to be associated with poorer psychological outcome, including psychosocial variables pretrauma and peritrauma, and acute stress. Parents’ scores on the PAS indicated that 64 (60%) were at risk of developing PTSD and 80 (75%) were at risk of developing depression following their child’s admission. Univariate analyses suggested that psychosocial variables, such as preexisting stressors and a history of previous mental health problems, were more strongly associated with PAS risk scores for PTSD and depression than medical or sociodemographic factors. In logistic regression analyses, a history of previous mental health problems was significantly associated with risk of developing PTSD and depression (p < 0.001) explaining 28% and 43% of the variance in these outcomes.  CONCLUSIONS: This study suggests that a significant number of parents on PICU are potentially at risk of developing PTSD and/or depression postdischarge and that psychosocial factors, pretrauma and peritrauma, are stronger determinants of this risk, and of acute distress, than other variables. Identification of vulnerable parents during admission, using a measure such as the PAS, could facilitate the targeting of support and monitoring, acutely and postdischarge, at those who might be most likely to benefit

Psychological impact of working in paediatric intensive care. A UK-wide prevalence study

OBJECTIVE: To determine the prevalence of work-related psychological distress in staff working in UK paediatric intensive care units (PICU). DESIGN: Online (Qualtrics) staff questionnaire, conducted April to May 2018. SETTING: Staff working in 29 PICUs and 10 PICU transport services were invited to participate. PARTICIPANTS: 1656 staff completed the survey: 1194 nurses, 270 physicians and 192 others. 234 (14%) respondents were male. Median age was 35 (IQR 28-44). MAIN OUTCOME MEASURES: The Moral Distress Scale-Revised (MDS-R) was used to look at moral distress, the abbreviated Maslach Burnout Inventory to examine the depersonalisation and emotional exhaustion domains of burnout, and the Trauma Screening Questionnaire (TSQ) to assess risk of post-traumatic stress disorder (PTSD). RESULTS: 435/1194 (36%) nurses, 48/270 (18%) physicians and 19/192 (10%) other staff scored above the study threshold for moral distress (≥90 on MDS-R) (χ2 test, p<0.00001). 594/1194 (50%) nurses, 99/270 (37%) physicians and 86/192 (45%) other staff had high burnout scores (χ2 test, p=0.0004). 366/1194 (31%) nurses, 42/270 (16%) physicians and 21/192 (11%) other staff scored at risk for PTSD (χ2 test, p<0.00001). Junior nurses were at highest risk of moral distress and PTSD, and junior doctors of burnout. Larger unit size was associated with higher MDS-R, burnout and TSQ scores. CONCLUSIONS: These results suggest that UK PICU staff are experiencing work-related distress. Further studies are needed to understand causation and to develop strategies for prevention and treatment

Patterns of post-traumatic stress symptoms in families after paediatric intensive care. Intensive Care Med 2012;38:1523–31

Abstract Purpose: To establish longitudinal rates of post-traumatic stress in a cohort of child-parent pairs; to determine associations with poorer outcome. Method: This was a prospective longitudinal cohort study set in a 21-bed unit. In total 66 consecutive admissions aged 7-17 years were screened with one parent at 3 and 12 months post-discharge. Measures used were the Children&apos;s Revised Impact of Event Scale (CRIES-8) and the SPAN (short form of Davidson Trauma Scale). Results: In total 29 (44 %) childparent pairs contained at least one member who scored above cut-off 12 months after discharge, with scores increasing over time for 18 parents and 26 children. At 3 months, 28 (42 %) parents and 20 (32 %) children scored above cut-off; at 12 months the rates were 18 (27 %) parents and 17 (26 %) children. Parents scoring above cut-off at 12 months were more likely to have had a child admitted non-electively (100 % vs. 77 %, p = 0.028); had higher 3-month anxiety scores (11.5 vs. 4.5, p = 0.001) and their children had higher post-traumatic stress scores at 3 months (14 vs. 8, p = 0.017). Children who scored above cut-off at 12 months had higher 3-month post-traumatic stress scores (18 vs. 7, p = 0.001) and higher Paediatric Index of Mortality (PIM) scores on admission (10 vs. 4, p = 0.037). Conclusions: The findings that (a) nearly half of families were still experiencing significant symptoms of post-traumatic stress 12 months after discharge; (b) their distress was predicted more by subjective than by objective factors and (c) many experienced delayed reactions, indicate the need for longerterm monitoring and more support for families in this situatio

Prediction of parental posttraumatic stress, anxiety and depression after a child's critical hospitalization

OBJECTIVE: To study the role of parental resilience, emotions accessed during admission and perceived stress in predicting the degree of parental posttraumatic stress disorder (PTSD), anxiety and depression symptoms after a child's treatment in intensive care. METHODS: This was prospective longitudinal cohort study. A total of 196 parents of pediatric intensive care survivors completed questionnaires assessing resilience, perceived stress, emotions experienced during admission, 48h post-discharge (T0). Sociodemographic and medical data were also collected. Main outcomes were anxiety, depression and PTSD, three (T1) and six (T2) months later. RESULTS: At T2, 23% of parents reported clinically significant levels of symptoms of PTSD, 21% reported moderate-severe anxiety, and 9% reported moderate-severe depression. These rates were not statistically different to rates at T1. Path analyses indicated that 47% of the variance in psychopathology symptoms at T2 could be predicted from the variables assessed at T0. Resilience was a strong negative predictor of psychopathology symptoms, but this effect was mostly indirect, mediated by the stress that parents perceive during their child's critical hospitalization. CONCLUSIONS: Mobilizing coping in order to maintain resilience and to decrease their perceived stress levels could improve parents' mental health outcomes following their child's intensive care treatment.Sin financiación2.783 JCR (2018) Q2, 16/33 Critical Care Medicine1.118 SJR (2018) Q1, 14/191 Critical Care and Intensive Care MedicineNo data IDR 2018UE