Karin Samuelson

Stressful memories and psychological distress in adult mechanically ventilated intensive care patients - a 2-month follow-up study

Aim:  To investigate patients’ psychological distress in relation to memory and stressful experiences in the intensive care unit (ICU), and to identify early predictors for the development of high levels of acute post‐traumatic stress disorder (PTSD)‐related symptoms.

Memory in relation to depth of sedation in adult mechanically ventilated intensive care patients

ObjectiveTo investigate the relationship between memory and intensive care sedation.Design and settingProspective cohort study over 18 months in two general intensive care units (ICUs) in district university hospitals.Patients313 intubated mechanically ventilated adults admitted for more than 24 h, 250 of whom completed the study.MeasurementsPatients (n = 250) were interviewed in the ward 5 days after discharge from the ICU using the ICU Memory Tool. Patient characteristics, doses of sedative and analgesic agents, and sedation scores as measured by the Motor Activity Assessment Scale (MAAS) were collected from hospital records after the interview.ResultsPatients with no recall (18%) were significantly older, had higher baseline severity of illness, and experienced fewer periods of wakefulness (median proportion of MAAS score 3; 0.37 vs. 0.70) than those who had memories of the ICU (82%). Multivariate analyses showed that increasing proportion of MAAS 0–2 and older age were significantly associated with having no recall. Patients with delusional memories (34%) had significantly longer ICU stay (median 6.6 vs. 2.2 days), higher baseline severity of illness, higher proportions of MAAS scores 4–6, and more administration of midazolam than those with recall of the ICU without delusional memories.ConclusionsHeavy sedation increases the risk of having no recall, and longer ICU stay increases the risk of delusional memories. The depth of sedation during total ICU stay as recorded with the MAAS may predict the probability of having memories of the ICU.

Intensive care sedation of mechanically ventilated patients: a national Swedish survey

Sedation in critically ill patients is a complex issue and at the same time an important concept for ensuring patient comfort. The aim of this study was to review the current practice of sedation for patients on mechanical ventilation in Swedish intensive care units (ICUs). Questionnaires were sent by post to head nurses in 89 ICUs with mechanically ventilated patients. By August 2000, 87 (98%) questionnaires had been returned. The results show that mechanically ventilated patients were routinely sedated in 91% of ICUs. Midazolam or propofol in combination with an opioid were the drugs preferred by 76%. Heavy sedation was most usual in 63% of ICUs but, when asked about the sedation level preferred by nurses, 78% chose light sedation (P=0.001). Only 16% used sedation scales. This study indicates that local habits and personal attitudes seem to have a great impact on sedation routines. It therefore appears worthwhile for ICUs to review their practice and, if necessary, to consider implementing sedation scales and sedation guidelines. Research pertaining to potential complications and patient comfort in relation to different sedation levels as well as further validation of the efficacy of sedation scales is needed.

ICU-recovery in Scandinavia: a comparative study of intensive care follow-up in Denmark, Norway and Sweden.

OBJECTIVES The aim of our study was to describe and compare models of intensive care follow-up in Denmark, Norway and Sweden to help inform clinicians regarding the establishment and continuation of ICU aftercare programmes. METHODS Our study had a multi-centre comparative qualitative design with triangulation of sources, methods and investigators. We combined prospective data from semi-structured key-informant telephone interviews and unreported data from a precursory investigation. RESULTS Four basic models of follow-up were identified representing nurse-led or multidisciplinary programmes with or without the provision of patient diaries. A conceptual model was constructed including a catalogue of interventions related to the illness trajectory. We identified three temporal areas for follow-up directed towards the past, present or future. CONCLUSIONS ICU follow-up programmes in the Scandinavian countries have evolved as bottom-up initiatives conducted on a semi-voluntary basis. We suggest reframing follow-up as an integral part of patient therapy. The Scandinavian programmes focus on the human experience of critical illness, with more attention to understanding the past than looking towards the future. We recommend harmonization of programmes with clear goals enabling programme assessment, while moving towards a paradigm of empowerment, enabling patient and family to take an active role in their recovery and wellbeing.

Light vs. heavy sedation during mechanical ventilation after oesophagectomy – a pilot experimental study focusing on memory

Background: To assess and compare the feasibility and stressful memories of light vs. heavy sedation during post‐operative mechanical ventilation.

Preferred content and usefulness of a photodiary as described by ICU-patients--a mixed method analysis.

UNLABELLED Many ICU-patients have memory-gaps which may affect their recovery. A tool in the recovery can be an ICU-diary to explain and clarify thoughts and events from the ICU-period. There are different standards for the content in the ICU-diary. The aim of this study was to identify the preferred content and usefulness of an ICU-diary as described by ICU-patients. METHOD A descriptive, exploratory cohort design with a mixed method approach. The patients answered a questionnaire (n=115) and participated in an interview (n=15) six months after the ICU-stay. Data analysis was carried out in three stages; the questionnaire was analysed by descriptive statistics and categorised by content (four open-ended questions) and the interviews were analysed by manifest content analysis. RESULTS The patients were explained that detailed information about daily activities and medical facts had to be included to understand and give a sense of coherence of what had happened. The content in the ICU-diary had to be chronological in order to follow the process in which photos were an important part. The patients re-read the ICU-diary during the recovery which helped them to fill in the memory gaps and used it as a tool for communication. CONCLUSION To construct a coherent story, it was essential that the ICU-diary was complete and were amplified by photos, all appearing in a chronological order. The results of this study could form a basis for further developments of standards and guidelines for ICU-diaries.

Impact of professionalism in nursing on in-hospital bedside monitoring practice.

AIM This article reports a study exploring nursing practice of monitoring in-hospital patients including intra- and interprofessional communication and collaboration. BACKGROUND Sub-optimal care in general in-hospital wards may lead to admission for intensive care, cardiac arrest, or sudden death. Reasons may include infrequent measurements of vital parameters, insufficient knowledge of their predictive values, and/or sub-optimal use of Medical Emergency Teams. This study was designed to improve understanding of nursing practice and to identify changes required to support nursing staff in improving standards of clinical monitoring practice and patient safety in general in-hospital wards. DESIGN The study was designed as a qualitative descriptive clinical study, based on method triangulation including structured individual observations and semi-structured individual interviews. METHODS In the spring of 2009, structured observations and semi-structured interviews of 13 nurses were carried out at a university hospital in Copenhagen, Denmark. The observational notes and interview transcriptions were analysed using content analysis. RESULTS One theme (Professionalism influences nursing monitoring practice) and two sub-themes (Knowledge and skills and Involvement in clinical practice through reflections) were identified. Three categories (Decision-making, Sharing of knowledge, and Intra- and interprofessional interaction) were found to be associated with the theme, the sub-themes, and with each other. CONCLUSION Clinical monitoring practice varies considerably between nurses with different individual levels of professionalism. Future initiatives to improve patient safety by further developing professionalism among nurses need to embrace individual and organizational attributes to strengthen their practice of in-hospital patient monitoring and management.

Lower incidence of unexpected in-hospital death after interprofessional implementation of a bedside track-and-trigger system

BACKGROUND In-hospital patients may suffer unexpected death because of suboptimal monitoring. Early recognition of deviating physiological parameters may enable staff to prevent unexpected in-hospital death. The aim of this study was to evaluate short- and long-term effects of systematic interprofessional use of early warning scoring, structured observation charts, and clinical algorithms for bedside action. METHODS A prospective non-randomized controlled study of unexpected in-hospital death before and after implementation of a clinical intervention in a medical and surgical ward setting at an urban Danish university hospital. Information was obtained over three four-month study periods - a pre-interventional one in 2009 (1st March-30th June), and two postinterventional ones in 2010 (1st September-31st December) and 2011 (1st March-30th June). The incidence of unexpected patient death, the primary study outcome, was calculated as the rate of unexpected patient mortality based on in-hospital risk time. RESULT The adjusted unexpected patient mortality rate was significantly lower during the second postinterventional study period than before the intervention, 17 versus 61 per 100 adjusted patient years (P=0.013), corresponding to a rate ratio of 0.271 (95% confidence interval (CI) 0.097-0.762). A tendency to reduced unexpected mortality was found during the first postinterventional study period (25 versus 61 per 100 adjusted patient years, P=0.053; rate ratio 0.404, CI 0.161-1.012). CONCLUSION Clinical intervention comprising systematic monitoring practice, early warning scoring, an observation chart, and an algorithm for bedside management, implemented by interprofessional teaching, training, and optimization of communication and collaboration, may significantly reduce unexpected in-hospital mortality.

The Richmond Agitation‐Sedation Scale: translation and reliability testing in a Swedish intensive care unit

Background: Awareness about adequate sedation in mechanically ventilated patients has increased in recent years. The use of a sedation scale to continually evaluate the patients response to sedation may promote earlier extubation and may subsequently have a positive effect on the length of stay in the intensive care unit (ICU). The Richmond Agitation‐Sedation Scale (RASS) provides 10 well‐defined levels divided into two different segments, including criteria for levels of sedation and agitation. Previous studies of the RASS have shown it to have strong reliability and validity. The aim of this study was to translate the RASS into Swedish and to test the inter‐rater reliability of the scale in a Swedish ICU.

The Intensive Care Delirium Screening Checklist: translation and reliability testing in a Swedish ICU

Background: The view of delirium has changed considerably over the last decade, and delirium is now a very topical issue within the intensive care unit (ICU) setting. Delirium has proved to be common in critically ill patients and is manifested as acute changes in mental status with reduced cognitive ability, incoherent thought patterns, impaired consciousness, agitation and acute confusion. In order to be able to prevent, identify and alleviate problems related to delirium it is important that validated instruments for delirium screening are implemented and evaluated. The aim of this study was to translate the Intensive Care Delirium Screening Checklist (ICDSC) into Swedish and test the inter‐rater reliability in a Swedish general ICU setting.