Interpersonal Communication in Intensive Care Units: A Qualitative Study on Family Members’ Experiences in a Turkish Public Hospital

Objective: Malnutrition is a significant problem among critically ill patients and is closely associated with poorer patient outcomes. With this study, we aimed to assess nutritional support practices and to evaluate the associated patient outcomes in intensive care units (ICU) in Turkey. Methods: This one-day, cross-sectional study was conducted in November 2015. A total of 1140 patients from 120 ICUs in 46 hospitals across Turkey were included. The general characteristics of the ICUs and patients, clinical data regarding nutritional support, hospitalization courses of the patients, and patient outcomes were recorded. The study questionnaire was prepared by the investigators and was completed by health care professionals from various hospital departments. Results: The mean age of the patients (55.7% were men) was 66.8±18.0 years. The median duration of the ICU stay was 17 days. Enteral tubes were present in 649 patients, of whom 79.4% had nasogastric tubes, 15.3% had percutaneous endoscopic gastrostomy (PEG) tubes, 4% had nasojejunal tubes, and 1.4% had surgical gastrostomy/jejunostomy tubes. 68.1% of ICUs had a nutritional support team. Nutritional support applied included enteral nutrition (44.1%), oral nutrition (25.9%), parenteral nutrition (18.5%), and enteral + parenteral nutrition (11.5%). On the 60th day, the mortality rate was 39.5%. Mortality rates were significantly lower in the oral nutrition group compared with the other groups, and were significantly higher in the parenteral nutrition group compared with the other groups. Conclusion: Our findings confirm the importance of nutritional support teams to provide timely and adequate administration of nutritional support and its association with better patient outcomes. Additionally, better outcomes were obtained with enteral nutrition compared with parenteral nutrition.

IntroductionThe aim of this study was to evaluate intensive care unit (ICU) performance using risk-adjusted ICU mortality rates nationally, assessing patients who died or had been discharged from the ICU. For this purpose, this study analyzed the Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) databases, containing detailed clinical and physiological information and mortality of mixed critically ill patients in a medical ICU at secondary and tertiary referral ICUs in Turkey.Material and methodsA total of 690 adult intensive care units in Turkey were included in the study. Among 690 ICUs evaluated, 39.7% were secondary and 60.3% were tertiary ICUs. A total of 4188 patients were enrolled in this study. Intensive care units of ministry, university, and private hospitals were evaluated all over Turkey. During the study period, clinical data that were collected concurrently for each patient contained demographic details and the diagnostic category leading to ICU admission. APACHE II and SOFA scores following ICU admission were calculated and recorded. Patients were followed up for outcome data until death or ICU discharge.ResultsThe mean age of patients was 68.8 ±19 and 54% of them were male. The mean APACHE II score was 20 ±8.7. The ICUs’ mortality rate was 46.3%, and mean predicted mortality was 37.2% for APACHE II. The standardized mortality ratio was 1.28 (95% confidence interval: 1.21–1.31).ConclusionsThere was a wide difference in outcome for patients admitted to different ICUs and severity of illness using risk adjustment methods. The high mortality rate in patients could be related to comorbid diseases, high mechanical ventilation rates and older ages.

Critical care workforce in crisis: A path forward

The objective of this review was to evaluate health care professionals' experiences when families participate in clinician handovers in adult, pediatric, and neonatal intensive care units (ICUs). Previous studies report the emotional distress families experience when a relative is admitted to intensive care, including an increased risk of post-traumatic stress disorder symptoms after discharge. Family involvement in patient care in ICU can improve safety and quality health care outcomes. Furthermore, family participation in clinician handovers may improve satisfaction with care, staff communication, and interpersonal relationships with families. However, health care professionals' attitudes toward family participation in multidisciplinary ward rounds are diverse, and little is known about their perspectives toward family participation in clinician handovers. Studies were included if they involved health care professionals and any type of family participation during handover, from bedside presence to participation in decision-making. Clinician handovers included multidisciplinary ward rounds or nursing handovers. Settings were adult, pediatric, or neonatal intensive care units in rural or metropolitan regions in any country. Studies in other clinical contexts were excluded. Qualitative studies were included, as well as mixed methods studies if qualitative data could be clearly extracted. Databases searched included CINAHL Plus (EBSCOhost), MEDLINE (Ovid), Scopus, Embase (Ovid), Emcare (Ovid), PsycINFO (Ovid), ProQuest Central (including ProQuest Dissertations and Theses), Web of Science, MedNar, and Google Scholar, with limiters being English and the year range 2000 to present. The last search was in October 2024. Two reviewers independently screened the titles and abstracts and assessed the full-text articles that met inclusion criteria for methodological quality. Findings were extracted using the JBI data extraction tool and assigned a level of credibility. Meta-aggregation was used to synthesize the findings. Two reviewers discussed any disagreements to reach consensus and consulted a third reviewer when necessary. Eleven studies published from 2003-2024 were included for data extraction. Five studies were qualitative and 6 were mixed methods. Six studies were conducted in the United States, 4 in Canada, and 1 in Australia. Three studies were in adult ICUs, 5 in pediatric, 1 in neonatal, and 2 did not specify the ICU type. All studies were on multidisciplinary bedside rounds, while none were conducted on nursing handovers. The findings revealed that health care professionals generally supported family participation in clinician handovers due to benefits such as improved communication between the health care team and families. However, they also identified barriers, including families' emotional responses to bad news and impact on workflow and teaching opportunities during handovers. Planning, leadership, and clear communication were highlighted as crucial for successfully facilitating family participation in rounds. While this review found that health care professionals value family participation in multidisciplinary bedside rounds, they experienced challenges. Future research is required to explore family participation in clinician handovers. Significant planning, investment and preparation is required to include families in ICU handovers. PROSPERO CRD42020223011.

Family ward rounds in intensive care: An integrative review of the literature

The purpose of this study was to investigate the prevalence of depression, anxiety disorder, hopelessness, and suicide among first-degree relatives of patients hospitalized in medical and anesthesia intensive care units at an academic medical centre. In this case-control study conducted in Türkiye, 32 first-degree relatives of 32 patients hospitalized for 14 days or more in intensive care units and 32 healthy volunteers were assessed. The Beck Depression Scale (BDS), Beck Anxiety Scale (BAS), Beck Hopelessness Scale (BHS), and Suicide Probability Scale (SPS) were administered to participants. The mean age of patients' relatives was 42.1 ± 11.6 years and that of the controls was 43.0 ± 11.3 years. The median scores for the BDS, BHS, and SPS were significantly higher among the relatives of the patients than among controls (P = .008, P = .013, and P = .001, respectively). Based on cutoff scores for the BDS and BAS, significant depressive symptoms were observed in 56.3% of the relatives of the patients and significant anxiety symptoms were observed in 46.9%. Among patients' relatives, the median score for the BDS was significantly higher among female participants than among male participants (P = .038). First-degree relatives of patients hospitalized in intensive care units have a higher prevalence of depression, hopelessness, and suicidality. Female relatives scored higher on depressive symptoms than male relatives. Psychiatric evaluation/screening of the relatives of patients hospitalized in intensive care units in Turkey is essential.

Familiesʼ Experiences of Having an Adult Family Member in a Critical Care Area: A Systematic Review of Quantitative Evidence

The objective of this study was to identify the characteristics of nonsurvivors in a pediatric intensive care unit (PICU) in Turkey. This is a retrospective analysis of patients who died in a tertiary PICU over a 6-year period from 2016 to 2021. Data were drawn from electronic medical records and resuscitation notes. Mode of death was categorized as failed cardiopulmonary resuscitation (F-CPR) or brain death. Among the 161 deaths, 136 nonsurvivors were included and 30.1% were younger than 1 year. Severe pneumonia, respiratory failure, and acute respiratory distress syndrome (ARDS) (31.6%) were the most common primary diagnoses. The most common mode of death was F-CPR (86.8%). More than half of the subjects had been admitted from pediatric emergency departments (58.1%), and more than half (53.7%) had died within 7 days in the PICU. Patients admitted from pediatric emergency departments had the lowest frequency of comorbidities (p < 0.001). Severe pneumonia, respiratory failure, and ARDS diagnoses were significantly more frequent in those who died after 7 days (p < 0.001), whereas septicemia, shock, and multiple organ dysfunction were more common among those who died within the first day of PICU admission (p < 0.001). It may be important to note that patients referred from wards are highly likely to have comorbidities, while those referred from pediatric emergency departments may be relatively younger. Additionally, patients with septicemia, shock, or multiple organ dysfunction were more likely to die earlier (within 7 days), especially compared with those with severe pneumonia, respiratory failure, or ARDS.

Recently several developed countries have improved the safety and efficacy of drugs used in infants and pediatric patients. Most drugs administered to adults have licensed approvals outlining indications, doses, and the recommended route of administration. However, many drugs that are given to children are unlicensed or used off-label. To assess the extent and nature of unregistered and off-label drug use in neonatal intensive care units (NICUs) in Turkey, and to explore awareness and views of the general public on the unlicensed use of medicine in preterm and term infants in developing countries. A prospective observational study of a dynamic cohort of 464 neonates from 17 NICUs in Turkey. All medications administered to neonates who were hospitalized and admitted to the NICU over a 24-h period were recorded. The prescriptions were analyzed to determine whether the medicines were used in a licensed or unlicensed manner. In total, 1,315 prescriptions comprising 93 different medicines were written. We found that 62.3% of the drugs prescribed to the neonates over the 24-h period were unlicensed or off-labeled. The present study indicates that unlicensed and off-label medicines are frequently used in preterm and term infants in Turkish NICUs. This finding is consistent and reported in other countries. We believe that the needs of the neonatal population must be a priority and access to safe and appropriate medicines requires urgent attention.

The need and values of patient- and family-centred care (PFCC) have been globally increasing in the health care landscape. However, the concept of PFCC and the components in adult intensive care units (ICUs) remain wide-ranging. To elucidate the core concepts of PFCC interventions and evaluate the effects of the interventions in adult ICUs. We searched electronic databases (PubMed, Cochrane Central, CINAHL, EMBASE, PsycINFO, RISS, KMbase and KoreaMed) from inception to 20 June 2022, for all studies on PFCC interventions. Three authors independently conducted data screening and extraction. The core concepts and the effects of PFCC interventions in adult ICUs were examined. The effects of patient- and family-centred care interventions in adult ICUs were examined. The quality of the included studies was evaluated using the Mixed Methods Appraisal Tool. Overall, 3507 records were identified, and 14 full-text articles were assessed. Participants in the included studies were patients and/or their family members in adult ICUs. The main concepts of the studies were participation and information-sharing. Only two studies used collaboration as the main concept of intervention. PFCC interventions have shown positive outcomes for patients, including increased satisfaction, improvement of patient health status and reduced incidence of complications. They have also been beneficial for families, leading to higher satisfaction levels and decreased anxiety. Additionally, these interventions have positively impacted health care providers by enhancing satisfaction and improving rounding efficiency. Moreover, they have influenced health care utilization by decreasing hospital costs and length of stay. This review highlights the advantages of PFCC interventions for patients, families and health care providers in adult ICUs. Future research should focus on developing strategies to incorporate collaboration more comprehensively as a core concept in the implementation of PFCC interventions. Future research endeavours must prioritize collaborative efforts involving health care providers, patients and their families by deploying an array of strategies within the intensive care unit setting.

Risk factors, characteristics, and outcomes of candidemia in an adult intensive care unit in Turkey

This paper is a report of a study to determine the opinions of physicians and nurses who work in a university hospital intensive care unit and emergency department about the presence of patients' families during cardiopulmonary resuscitation in these units. Healthcare professionals have conflicting opinions about the presence of patients' families during cardiopulmonary resuscitation. Families who are allowed to be present have less fear and worry, feel they have supported their family member and are able to cope more easily. The data for this descriptive questionnaire study were collected between November 2006 and January 2007. The respondents were 62 physicians and 82 nurses who worked in an emergency department or in cardiology or anaesthesia intensive care units in Turkey. The data were collected using a questionnaire and the responses summarized using frequencies and percentages. The chi-squared test was performed to test for differences in the opinion by profession, educational level, or number of years of working experience in the profession. The response rate was 79%. Of the respondents, 82.6% did not think it was appropriate for patients' families to be present during cardiopulmonary resuscitation. The most common concerns mentioned were that the family would interfere with the team's activities (56.3%) and that resuscitation is a very traumatic procedure (43.6%). Policies need to be developed regarding this topic because the absence of policy can cause misunderstanding and differences in practice. Further research is needed to determine what public education is needed to facilitate implementation of such policies.

Critical care and the global burden of critical illness in adults

ObjectiveDeveloping effective strategies to improve shared decision-making (SDM) about potentially non-beneficial intensive care unit (ICU) treatments for patients with advanced medical illness requires understanding patients' and family members' perspectives. This study explores family members' experiences in discussing potentially non-beneficial treatments with ICU clinicians to identify factors that influenced their decision-making.MethodsSemi-structured interviews of pre-dominantly non-White family members making decisions about potentially non-beneficial ICU treatments were conducted in the medical ICU of an academic public hospital in Los Angeles County. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis.ResultsEighteen surrogate decision-makers were interviewed for this study. Perceived barriers to decision-making included intimidation, dehumanizing family meetings, time-pressure to make decisions, and uncertainty of benefit from ICU treatments. Factors that affected the perceived susceptibility from harm or likelihood of benefit from invasive treatments included health status prior to hospitalization, physicians' discussion of prognoses, and direct observation of clinical status during ICU hospitalization. Greater self-efficacy in making decisions was promoted by stronger family support, gaining experience with the clinical situation, and empathic characteristics of the clinical team.ConclusionsInterviews with family members at a single ICU revealed that strategies to improve decision-making may include emphasizing empathic communication styles that focus on patients' values and preferences for care, reducing time-pressure and uncertainty by seeing the effects of ICU treatments, and creating time for families to adjust and seek social support. Adopting this approach may allow ICU clinicians and family members to become more aligned in their efforts to provide compassionate care for patients while minimizing non-beneficial treatments. These findings need to be validated in larger patient populations.

OBJECTIVE: To compare resource utilization and outcomes between cohorts of pediatric and adult intensive care unit (ICU) patients from a single institution. DESIGN: Prospective, observational cohort study. SETTING: A large, urban, tertiary care medical center. PATIENTS: A total of 780 patients consecutively admitted to the pediatric ICU, adult medical ICU, and adult surgical ICU. MEASUREMENTS AND MAIN RESULTS: ICU, hospital and 6-month survivals and hospital costs from index ICU admission. Predicted mortality by Pediatric Risk of Mortality III and Acute Physiology and Chronic Health Evaluation II. Health status at 6 months from index ICU admission. Pediatric patients had lower ICU (7.8% vs. 13.7%; p =.01), hospital (10.1% vs. 16.9%; p =.009), and 6-month (16.2% vs. 29.2%; p <.001) mortalities compared with adult patients. Adult patients had significantly lower probability of survival for 6 months from initial ICU admission compared with pediatric patients. The difference in survival was primarily accounted for by adult and pediatric medical patients. No differences could be observed between pediatric and adult ICU patients for mean hospital costs ($33,316 +/- $48,467 vs. $32,877 +/- $46,411; p =.92). Pediatric and adult patients incurred increasing costs with increasing risks of mortality. More than 50% of pediatric patients had a risk of mortality <0.5% compared with 1.2% of adult patients, but there was no difference in the mean use of ICU-specific interventions. CONCLUSIONS: Pediatric critical care patients have better short-term and longer-term survival compared with adult patients. The difference in survival is accounted for by the lower survival of adult medical patients. Despite the survival differences, pediatric and adult ICU patients incur similar hospital costs, and the proportions of patients who receive active ICU interventions are similar.