“Releasing a Lot of Poisons from My Mind”: Patients\u27 Delusional Memories of Intensive Care

Objectives To describe intensive care unit (ICU) patients\u27 delusional memories and interpretations of those memories. Background Delusional memories of the ICU are distressing for patients and may impact psychological recovery. Methods This is a secondary analysis from a study of mechanically ventilated patients\u27 recall in relation to sedation. Subjects, recruited from one medical-surgical ICU, participated in structured interviews after extubation. Results Subjects (n = 35) with a mean age of 66 (SD 12.9) and on the ventilator a median of 4.5 days provided detailed descriptions of delusional memories of being shackled, caged, strangled, or being in a foreign country. Delusions were very real and frightening in the moment. Subjects had difficulty connecting to reality to allow processing of the delusions. Conclusions Patients\u27 delusional memories of ICU share common distressing themes. Assisting patients\u27 to connect to real ICU events and process delusional memories may help with psychological recovery after critical illness

“Not Being Able to Talk Was Horrid”: A Descriptive, Correlational Study of Communication During Mechanical Ventilation

Objectives: The purpose of this study was to describe the patient experience of communication during mechanical ventilation. Research methodology: This descriptive study is a secondary analysis of data collected to study the relationship between sedation and the MV patients’ recall of the ICU. Interviews, conducted after extubation, included the Intensive Care Experience Questionnaire. Data were analysed with Spearman correlation coefficients (rs) and content analysis. Setting: Participants were recruited from a medical-surgical intensive care unit in the Midwest United States. Results: Participants (n = 31) with a mean age of 65 ± 11.9 were on the ventilator a median of 5 days. Inability to communicate needs was associated with helplessness (rs = .43). While perceived lack of information received was associated with not feeling in control (rs = 41) and helplessness (rs = 41). Ineffective communication impacted negatively on satisfaction with care. Participants expressed frustration with failed communication and a lack of information received. They believed receipt of information helped them cope and desired a better system of communication during mechanical ventilation. Conclusion: Communication effectiveness impacts patients’ sense of safety and well-being during mechanical ventilation. Greater emphasis needs to be placed on the development and integration of communication strategies into critical care nursing practice

Patients’ Experiences of Recovery: Beyond the Intensive Care Unit and into the Community

Aims To understand barriers and facilitators of recovery for critical illness survivors’, who are discharged home from the hospital and do not have access to dedicated outpatient care. Design Multi-site descriptive study guided by interpretive phenomenology using semi-structured interviews. Methods Interviews were conducted between December 2017 -July 2018. Eighteen participants were included. Data were collected from interview recordings, transcripts, field notes, and a retrospective chart review for sample demographics. Analysis was completed using Interpretive Phenomenological Analysis which provided a unique view of recovery through the survivors’ personal experiences and perception of those experiences. Results Participants encountered several barriers to their recovery; however, they were resilient and initiated ways to overcome these barriers and assist with their recovery. Facilitators of recovery experienced by survivors included seeking support from family and friends, lifestyle adaptations, and creative management of their multiple medical needs. Barriers included unmet needs experienced by survivors such as mental health issues, coordination of care, and spiritual needs. These unmet needs left participants feeling unsupported from healthcare providers during their recovery. Conclusion This study highlights important barriers and facilitators experienced by critical illness survivors during recovery that need be addressed by healthcare providers. New ways to support critical illness survivors, that can reach a broader population, must be developed and evaluated to support survivors during their recovery in the community. Impact This study addressed ICU survivors’ barriers and facilitators to recovery. Participants encountered several barriers to recovery at home, such as physical, cognitive, psychosocial, financial, and transportation barriers, however, these survivors were also resilient and resourceful in the development of strategies to try to manage their recovery at home. These results will help healthcare providers develop interventions to better support ICU survivors in the community

Tailoring a Treatment Fidelity Framework for an Intensive Care Unit Clinical Trial

Background: Treatment fidelity (TF) refers to methodological strategies and practices used to monitor and enhance the reliability and validity of behavioral interventions. Treatment fidelity monitoring enhances internal and external validity and is needed for study replication and generalizability. Objectives: The aim of this study was to describe the implementation, monitoring, and impact of TF in an intensive-care-unit-based clinical trial testing music for anxiety self-management with mechanically ventilated patients. Method: Development of the criteria was based on the Five-Component Treatment Fidelity Framework from the Treatment Fidelity Workgroup. Descriptive statistics were used to evaluate adherence rates to the key TF criteria and the reasons criteria were unmet. Descriptive and nonparametric statistics were used to evaluate the impact of TF on participants\u27 use of the assigned intervention. Results: The Treatment Fidelity Framework was adapted easily to fit the study interventions. After the initial implementation phase of monitoring, adherence to key criteria was maintained at the targeted level of 80%. The majority of barriers to adherence affected the research nurses\u27 opportunity to interact with the participant and encourage use of the intervention. There was a trend toward increased use of equipment associated with the assigned condition after the initiation of TF; however, this difference was not statistically significant. Discussion: Treatment fidelity monitoring is an iterative process that requires ongoing vigilance. Identification of barriers and the implementation of methods to enhance protocol adherence are needed to enhance the reliability, validity, and generalizability of clinical trials in the dynamic and challenging research environment of the intensive care unit

Sedation is tricky : A qualitative content analysis of nurses\u27 perceptions of sedation administration in mechanically ventilated intensive care unit patients

Introduction Critical care nurses are responsible for administering sedative medications to mechanically ventilated patients. With significant advancements in the understanding of the impact of sedative exposure on physiological and psychological outcomes of ventilated patients, updated practice guidelines for assessment and management of pain, agitation, and delirium in the intensive care unit were released in 2013. The primary aim of this qualitative study was to identify and describe themes derived from critical care nurses\u27 comments regarding sedation administration practices with mechanically ventilated patients. Methods This is a qualitative content analysis of secondary text data captured through a national electronic survey of members of the American Association of Critical-Care Nurses. A subsample (n = 67) of nurses responded to a single, open-ended item at the end of a survey that evaluated nurses\u27 perceptions of current sedation administration practices. Findings Multiple factors guided sedation administration practices, including individual patient needs, nurses\u27 synthesis of clinical evidence, application of best practices, and various personal and professional practice perspectives. Our results also indicated nurses desire additional resources to improve their sedation administration practices including more training, better communication tools, and adequate staffing. Conclusions Critical care nurses endorse recommendations to minimise sedation administration when possible, but a variety of factors, including personal perspectives, impact sedation administration in the intensive care unit and need to be considered. Critical care nurses continue to encounter numerous challenges when assessing and managing sedation of mechanically ventilated patients

Sedation is tricky : A qualitative content analysis of nurses\u27 perceptions of sedation administration in mechanically ventilated intensive care unit patients

Introduction Critical care nurses are responsible for administering sedative medications to mechanically ventilated patients. With significant advancements in the understanding of the impact of sedative exposure on physiological and psychological outcomes of ventilated patients, updated practice guidelines for assessment and management of pain, agitation, and delirium in the intensive care unit were released in 2013. The primary aim of this qualitative study was to identify and describe themes derived from critical care nurses\u27 comments regarding sedation administration practices with mechanically ventilated patients. Methods This is a qualitative content analysis of secondary text data captured through a national electronic survey of members of the American Association of Critical-Care Nurses. A subsample (n = 67) of nurses responded to a single, open-ended item at the end of a survey that evaluated nurses\u27 perceptions of current sedation administration practices. Findings Multiple factors guided sedation administration practices, including individual patient needs, nurses\u27 synthesis of clinical evidence, application of best practices, and various personal and professional practice perspectives. Our results also indicated nurses desire additional resources to improve their sedation administration practices including more training, better communication tools, and adequate staffing. Conclusions Critical care nurses endorse recommendations to minimise sedation administration when possible, but a variety of factors, including personal perspectives, impact sedation administration in the intensive care unit and need to be considered. Critical care nurses continue to encounter numerous challenges when assessing and managing sedation of mechanically ventilated patients

Factors Influencing Nurse Sedation Practices with Mechanically Ventilated Patients: A U.S. National Survey

Objectives Mechanically ventilated patients commonly receive sedative medications. There is increasing evidence that sedative medications impact on patient outcomes. Nursing behaviour is a key determinant of sedation administration. The purpose of this study was to determine factors that influence nurse sedation administration to mechanically ventilated patients. Methods The Nurse Sedation Practices Scale was mailed to a random sample of 1250 members of the American Association of Critical Care Nurses. Results A response rate of 39% was obtained. Respondents were primarily staff nurses (73%) with a bachelor\u27s degree in nursing (59%) from various intensive care unit (ICU) settings. We limited the analysis to adult ICU practitioners (n = 423). The majority of nurses (81%) agreed that sedation is necessary for patient comfort. Nurse attitudes towards the efficacy of sedation for mechanically ventilated patients was positively correlated with nurses’ report of their sedation practice ( = .28, p \u3c .001) and their intent to administer sedation ( = .58, p \u3c .001). Attitudes did not vary with respect to individual or practice setting characteristics. Conclusion Nurses’ attitudes impact sedation administration practices. Modifying nurses’ attitudes on sedation and the experience of mechanical ventilation may be necessary to change sedation practices with mechanically ventilated patients

Effects of Patient-Directed Music Intervention on Anxiety and Sedative Exposure in Critically Ill Patients Receiving Mechanical Ventilatory Support: A Randomized Clinical Trial

Importance: Alternatives to sedative medications, such as music, may alleviate the anxiety associated with ventilatory support. Objective: To test whether listening to self-initiated patient-directed music (PDM) can reduce anxiety and sedative exposure during ventilatory support in critically ill patients. Design, Setting, and Patients: Randomized clinical trial that enrolled 373 patients from 12 intensive care units (ICUs) at 5 hospitals in the Minneapolis-St Paul, Minnesota, area receiving acute mechanical ventilatory support for respiratory failure between September 2006 and March 2011. Of the patients included in the study, 86% were white, 52% were female, and the mean (SD) age was 59 (14) years. The patients had a mean (SD) Acute Physiology, Age and Chronic Health Evaluation III score of 63 (21.6) and a mean (SD) of 5.7 (6.4) study days. Interventions: Self-initiated PDM (n = 126) with preferred selections tailored by a music therapist whenever desired while receiving ventilatory support, self-initiated use of noise-canceling headphones (NCH; n = 122), or usual care (n = 125). Main Outcomes and Measures: Daily assessments of anxiety (on 100-mm visual analog scale) and 2 aggregate measures of sedative exposure (intensity and frequency). Results: Patients in the PDM group listened to music for a mean (SD) of 79.8 (126) (median [range], 12 [0-796]) minutes/day. Patients in the NCH group wore the noise-abating headphones for a mean (SD) of 34.0 (89.6) (median [range], 0 [0-916]) minutes/day. The mixed-models analysis showed that at any time point, patients in the PDM group had an anxiety score that was 19.5 points lower (95% CI, −32.2 to −6.8) than patients in the usual care group (P = .003). By the fifth study day, anxiety was reduced by 36.5% in PDM patients. The treatment × time interaction showed that PDM significantly reduced both measures of sedative exposure. Compared with usual care, the PDM group had reduced sedation intensity by −0.18 (95% CI, −0.36 to −0.004) points/day (P = .05) and had reduced frequency by −0.21 (95% CI, −0.37 to −0.05) points/day (P = .01). The PDM group had reduced sedation frequency by −0.18 (95% CI, −0.36 to −0.004) points/day vs the NCH group (P = .04). By the fifth study day, the PDM patients received 2 fewer sedative doses (reduction of 38%) and had a reduction of 36% in sedation intensity. Conclusions and Relevance: Among ICU patients receiving acute ventilatory support for respiratory failure, PDM resulted in greater reduction in anxiety compared with usual care, but not compared with NCH. Concurrently, PDM resulted in greater reduction in sedation frequency compared with usual care or NCH, and greater reduction in sedation intensity compared with usual care, but not compared with NCH. Trial Registration: clinicaltrials.gov Identifier: NCT00440700 Critically ill mechanically ventilated patients receive intravenous sedative and analgesic medications to reduce anxiety and promote comfort and ventilator synchrony. These potent medications are often administered at high doses for prolonged periods and are associated with adverse effects such as bradycardia, hypotension, gut dysmotility, immobility, weakness, and delirium.1-3 Despite protocols and sedation assessment tools that guide clinicians, patients still experience significant levels of anxiety.4,5 Unrelieved anxiety and fear are not only unpleasant symptoms that clinicians want to palliate, but increased sympathetic nervous system activity can cause dyspnea and increased myocardial oxygen demand.6 Sustained anxiety and sympathetic nervous system activation can decrease the ability to concentrate, rest, or relax.6,7 Mechanically ventilated patients have little control over pharmacological interventions to relieve anxiety; dosing and frequency of sedative and analgesic medications are controlled by intensive care unit (ICU) clinicians. Interventions are needed that reduce anxiety, actively involve patients, and minimize the use of sedative medications. Nonpharmacological interventions such as relaxing music are effective in reducing anxiety while reducing medication administration.8,9 Music is a powerful distractor that can alter perceived levels of anxiety10 by occupying attention channels in the brain with meaningful, auditory stimuli11 rather than stressful environmental stimuli. Listening to preferred, relaxing music has reduced anxiety in mechanically ventilated patients in limited trials.12-15 It is not known if music can reduce anxiety throughout the course of ventilatory support, or reduce exposure to sedative medications. We evaluated if a patient-directed music (PDM) intervention could reduce anxiety and sedative exposure in ICU patients receiving mechanical ventilation

Advance Directives and Intensity of Care Delivered to Hospitalized Older Adults at The End-of-Life

Background Older adults prefer comfort over life-sustaining care. Decreased intensity of care is associated with improved quality of life at the end-of-life (EOL). Objectives This study explored the association between advance directives (ADs) and intensity of care in the acute care setting at the EOL for older adults. Methods A retrospective, correlational study of older adult decedents (N = 496) was conducted at an academic medical center. Regression analyses explored the association between ADs and intensity of care. Results Advance directives were not independently predictive of aggressive care but were independently associated with referrals to palliative care and hospice; however, effect sizes were small, and the timing of referrals was late. Conclusion The ineffectiveness of ADs to reduce aggressive care or promote timely referrals to palliative and hospice services, emphasizes persistent inadequacies related to EOL care. Research is needed to understand if this failure is provider-driven or a flaw in the documents themselves