Protocol for a mixed-methods exploratory investigation of care following intensive care discharge: the REFLECT study

© Author(s) 2019. Re-use permitted under CC BY. Published by BMJ.INTRODUCTION: A substantial number of patients discharged from intensive care units (ICUs) subsequently die without leaving hospital. It is unclear how many of these deaths are preventable. Ward-based management following discharge from ICU is an area that patients and healthcare staff are concerned about. The primary aim of REFLECT (Recovery Following Intensive Care Treatment) is to develop an intervention plan to reduce in-hospital mortality rates in patients who have been discharged from ICU. METHODS AND ANALYSIS: REFLECT is a multicentre mixed-methods exploratory study examining ward care delivery to adult patients discharged from ICU. The study will be made up of four substudies. Medical notes of patients who were discharged from ICU and subsequently died will be examined using a retrospective case records review (RCRR) technique. Patients and their relatives will be interviewed about their post-ICU care, including relatives of patients who died in hospital following ICU discharge. Staff involved in the care of patients post-ICU discharge will be interviewed about the care of this patient group. The medical records of patients who survived their post-ICU stay will also be reviewed using the RCRR technique. The analyses of the substudies will be both descriptive and use a modified grounded theory approach to identify emerging themes. The evidence generated in these four substudies will form the basis of the intervention development, which will take place through stakeholder and clinical expert meetings. ETHICS AND DISSEMINATION: Ethical approval has been obtained through the Wales Research and Ethics Committee 4 (17/WA/0107). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media. TRIAL REGISTRATION NUMBER: ISRCTN14658054.Peer reviewedFinal Published versio

‘Doing the best we can’: Registered Nurses' experiences and perceptions of patient safety in intensive care during COVID-19

Aims: To explore registered nurses' experiences of patient safety in intensive care during COVID-19.Design: A qualitative interview study informed by constructivism. Method: Semi-structured interviews were conducted and audio- recorded with 19 registered nurses who worked in intensive care during COVID-19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework. Results: Two key themes were identified. ‘On a war footing’—an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. ‘Doing the best we can’—Safe Delivery of Care which describes the ramifications of the actions taken on short- and long-term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well-being and Peer Support. Conclusion: Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an under-standing of the holistic and long-term impacts on patient safety and recovery from critical illness. Impact: This study explored the perceived impact of COVID-19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long-term appreciation of patient safety. These findings should be considered as part of future nursing work-force modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professional

Very High Temperature Reactor (VHTR) Survey of Materials Research and Development Needs to Support Early Deployment

The VHTR reference concept is a helium-cooled, graphite moderated, thermal neutron spectrum reactor with an outlet temperature of 1000 C or higher. It is expected that the VHTR will be purchased in the future as either an electricity producing plant with a direct cycle gas turbine or a hydrogen producing (or other process heat application) plant. The process heat version of the VHTR will require that an intermediate heat exchanger (IHX) and primary gas circulator be located in an adjoining power conversion vessel. A third VHTR mission - actinide burning - can be accomplished with either the hydrogen-production or gas turbine designs. The first ''demonstration'' VHTR will produce both electricity and hydrogen using the IHX to transfer the heat to either a hydrogen production plant or the gas turbine. The plant size, reactor thermal power, and core configuration will be designed to assure passive decay heat removal without fuel damage during accidents. The fuel cycle will be a once-through very high burnup low-enriched uranium fuel cycle. The purpose of this report is to identify the materials research and development needs for the VHTR. To do this, we focused on the plant design described in Section 2, which is similar to the GT-MHR plant design (850 C core outlet temperature). For system or component designs that present significant material challenges (or far greater expense) there may be some viable design alternatives or options that can reduce development needs or allow use of available (cheaper) materials. Nevertheless, we were not able to assess those alternatives in the time allotted for this report and, to move forward with this material research and development assessment, the authors of this report felt that it was necessary to use a GT-MHR type design as the baseline design

What's in this issue? (Volume 26, Issue 4)

Editorial

Randomised controlled trials in critical care nursing : essential to move practice forward

Editorial

How to write an abstract for an intensive care conference

Editorial

A human factors analysis of missed mobilisation after discharge from intensive care: a competition for care?

Background Patients discharged to the ward from an intensive care unit (ICU) commonly experience a reduction in mobility but few mobility interventions. Barriers and facilitators for mobilisation on acute wards after discharge from an ICU were explored. Design and methods A human factors analysis was undertaken using the Functional Resonance Analysis Method (FRAM) as part of the Recovery Following Intensive Care Treatment (REFLECT) study. A FRAM focus group was formed from members of the ICU and ward multidisciplinary teams from two hospitals, with experience of working in six hospitals. They identified factors influencing mobilisation and the interdependency of these factors. Results Patients requiring discharge assessments or on Enhanced Recovery After Surgery (ERAS) pathways compete for priority with post-ICU patients with more urgent rehabilitation needs. Patients unable to stand and step to a chair or requiring mobilisation equipment were deemed particularly susceptible to missing mobilisation interventions. The ability to mobilise was perceived to be highly influenced by multidisciplinary staffing levels and skill mix. These factors are interdependent in facilitating or inhibiting mobilisation. Conclusions This human factors analysis of post-ICU mobilisation highlighted several influencing factors and demonstrated their interdependency. Future interventions should focus on mitigating competing priorities to ensure regular mobilisation, target patients unable to stand and step to a chair on discharge from ICU and create robust processes to ensure suitable equipment availability. Trial registration number ISRCTN1465805