Intensive Care Unit Team Research Articles

Pembrolizumab: a case of drug‐induced autoimmune diabetes mellitus and colitis

AbstractBackgroundImmunosuppressive molecules such as cytotoxic T lymphocyte‐associated antigen 4 (CTLA‐4), programmed cell death protein (PD‐1) and its ligand (PD‐L1) are markedly overexpressed in the tumour microenvironment, providing a means for immune escape. Targeting these molecules, novel immunotherapies manipulate the host immune system to better detect and kill cancer cells. This paper describes a case of drug‐induced autoimmune colitis and type 1 diabetes mellitus (T1DM) attributed to pembrolizumab.Clinical detailsA 70‐year‐old male presented with a 1‐week history of diarrhoea, vomiting, mucositis and loss of appetite following his third treatment with pembrolizumab infusion for metastatic melanoma. The patient's pathology results and clinical symptoms were consistent with a diagnosis of colitis and diabetic ketoacidosis (DKA).OutcomesThe patient's symptoms resolved with interventions from the intensive care unit (ICU), endocrinology and gastroenterology teams. Due to the severity of the adverse drug reaction, pembrolizumab was ceased. The patient was discharged from the hospital with insulin for his T1DM and a 1‐month course of weaning prednisolone for his colitis.ConclusionThe potential for autoimmune side effects associated with pembrolizumab may not be fully recognised by all clinicians. This case report highlights the potential for serious adverse events and serves to demonstrate the requirement for clinicians to develop a routine approach for early identification and management of these events.

Psychological care in the intensive care unit : Task areas, responsibilities, requirements, and infrastructure

The relatively high rates of mental stress among critically ill patients and their relatives implies the necessity of conceptually and financially embedded psychological care in intensive care units (ICUs). Professional associations also recommend the involvement of psychological professionals and screening of mental symptoms in critically ill patients. Intensive care medicine psychologists and psychotherapists take this as an opportunity to describe the content and goals of psychological care. Task areas are care for patients and relatives as well as staff support. Goals of psychological support in the ICU are detection of mental symptoms in patients and their treatment, psychological first aid for relatives in crisis situations, and support of the staff in terms of communication with patients and relatives as well as regarding development and maintenance of an adaptive coping style for dealing with emotionally challenging situations. Psychological care in the ICU is offered by psychologists, psychotherapists, or physicians with apsychotherapeutic qualification. The psychologist is integrated into the ICU team and has aproactive, resource-oriented, and supportive orientation. Psychological support can be an enrichment and arelief, both in the interdisciplinary treatment of patients as well as in the care of relatives, and also represent aresource for the team.

The critical nature of debriefing in high‐fidelity simulation‐based training for improving team communication in emergency resuscitation

SummaryEmergency resuscitation in intensive care units (ICUs) requires effective team communication to orchestrate the joint performance of several individuals. Although team simulation training has proven an effective means to improve communication skills in high‐risk environments, the influence of debriefing content on simulation‐based learning is less clear. In this study, 10 ICU teams completed three consecutive cardiac resuscitation scenarios, followed by a 3‐month follow‐up. Control teams received a debriefing on the basis of resuscitation technical skills after each of the first three scenarios, whereas the experimental teams' debriefing focused on team communication. Results showed that although information sharing improved for all teams, communication quality improved only for experimental teams, and these training benefits dissipated after 3 months. The study helps develop a methodology for assessing team communication and highlights the importance of frequent team simulation‐based training and debriefing in emergency medicine that includes both technical and nontechnical skills.

Sink traps as the source of transmission of OXA-48-producing Serratia marcescens in an intensive care unit.

Carbapenemase-producing Enterobacteriaceae (CPE) outbreaks are mostly attributed to patient-to-patient transmission via healthcare workers. We describe successful containment of a prolonged OXA-48-producing S. marcescens outbreak after recognizing the sink traps as the source of transmission. The Sheba Medical Center intensive care unit (ICU), contains 16 single-bed, semi-closed rooms. Active CPE surveillance includes twice-weekly rectal screening of all patients. A case was defined as a patient detected with OXA-48 CPE >72 hours after admission. A root-cause analysis was used to investigate the outbreak. All samples were inoculated on chrom-agar CRE, and carbapenemase genes were detected using commercial molecular Xpert-Carba-R. Environmental and patient S. marcescens isolates were characterized using PFGE. From January 2016 to May 2017, 32 OXA-48 CPE cases were detected, and 81% of these were S. marcescens. A single clone was the cause of all but the first 2 cases. The common factor in all cases was the use of relatively large amounts of tap water. The outbreak clone was detected in 2 sink outlets and 16 sink traps. In addition to routine strict infection control measures, measures taken to contain the outbreak included (1) various sink decontamination efforts, which eliminated the bacteria from the sink drains only temporarily and (2) educational intervention that engaged the ICU team and lead to high adherence to 'sink-contamination prevention guidelines.' No additional cases were detected for 12 months. Despite persistence of the outbreak clones in the environmental reservoir for 1 year, the outbreak was rapidly and successfully contained. Addressing sink traps as hidden reservoirs played a major role in the intervention.

Improving transitions of care between the operating room and intensive care unit.

Transitions of care between individual providers or teams of providers have a high potential for errors due to the incomplete transfer of critical information and the need for ongoing care. The transition from the operating room (OR) to the intensive care unit (ICU) is a particularly dangerous time for critically ill children. Hand-offs of care between the OR and ICU teams during this key transition period require detailed communication of complete and accurate patient information at a time when the patient is perhaps most vulnerable from a physiologic standpoint. Improving the safety of transitions from the OR to the ICU is an active area of investigation, though there are a few notable best practices that are commonly employed in a number of centers. These best practices include having the appropriate personnel at the bedside for the hand-off, the use of scripts and the "sterile cockpit rule", the use of checklists, double verification of post-operative orders, and maintaining an overall safety culture.

Use of REBOA to stabilize in-hospital iatrogenic intra-abdominal hemorrhage

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become an increasingly popular alternative to emergency thoracotomy and aortic cross-clamping in patients with exsanguinating hemorrhage.1 This new capability is increasingly...

AI in the ICU: In the intensive care unit, artificial intelligence can keep watch

IN A HOSPITAL'S INTENSIVE CARE UNIT (ICU), the sickest patients receive round-the-clock care as they lie in beds with their bodies connected to a bevy of surrounding machines. This advanced medical equipment is designed to keep an ailing person alive. Intravenous fluids drip into the bloodstream, while mechanical ventilators push air into the lungs. Sensors attached to the body track heart rate, blood pressure, and other vital signs, while bedside monitors graph the data in undulating lines. When the machines record measurements that are outside of normal parameters, beeps and alarms ring out to alert the medical staff to potential problems. • While this scene is laden with high tech, the technology isn't being used to best advantage. Each machine is monitoring a discrete part of the body, but the machines aren't working in concert. The rich streams of data aren't being captured or analyzed. And it's impossible for the ICU team—critical-care physicians, nurses, respiratory therapists, pharmacists, and other specialists—to keep watch at every patient's bedside. • The ICU of the future will make far better use of its machines and the continuous streams of data they generate. Monitors won't work in isolation, but instead will pool their information to present a comprehensive picture of the patient's health to doctors. And that information will also flow to artificial intelligence (AI) systems, which will autonomously adjust equipment settings to keep the patient in optimal condition.

“EVEN LISTENING IS GOOD”: COMPARING AN ACTIVE AND PASSIVE PARTICIPATION OF FAMILIES IN MULTIDISCIPLINARY ROUNDS

SESSION TITLE: Improving Patient Care Through System Change SESSION TYPE: Original Investigations PRESENTED ON: 10/10/2018 02:30 pm - 03:30 pm PURPOSE: Studies have shown that keeping open information with families not only improves satisfaction but also improves the overall performance outcome of an Intensive Care Unit (ICU) [1]. It was therefore hypothesized that if a patient’s family was given the chance to be either actively or passively involved in the multidisciplinary rounds (MDRs), their satisfaction can be measured objectively. Searching of literature shows that we are the first to compare between active (AP) and passive participation (PP) of families in MDRs. METHODS: This observational study was performed in a 40 bed Cardio-Vascular ICU of a tertiary care center. Data was collected from the each weekday morning’s formal MDRs involving an intensivist, a bedside nurse, unit manager, a pharmacist, a dietician, a social worker, a respiratory therapist, a physical therapist and a chaplain. No patient identifying data were collected or preserved. A patient’s case is discussed, with recent updates, by the bedside nurse or an intensivist. Families are allowed to observe this discussion and are provided the opportunity to actively ask any questions. A total of 266 beds were rounded with 121 families present. Out of the 121 families present during the rounds, 73 scores were retained after they satisfy all inclusion questions. A five point satisfaction score is developed depending on understanding of the plan of the care for the day as well as overall goal of the treatment, opportunity to ask questions, opportunity to raise concerns and on the doctors’ communication skills. RESULTS: Out of 73 scores, 34 were from families that were active in the rounds (AP group) and 39 were from families that only passively listened to the discussion of providers (PP group). STATA © biostatistic software is used to satisfy sample size in each arm to obtain mean, histogram, power of 80%, equal variance, level of significance of .05 (Type 1 error) with standard deviation estimated using sample T-distribution. Z for 95% Confidence Interval (CI) = 1.96, 95% CI of difference: -0.3393 <0.333< 1.0053 (Wald), t= 0.971; df= 33; p= 0.83066 (left p: 0.1693; two sided: 0.3386). CONCLUSIONS: As we failed to reject our null hypothesis, we concluded that even passive participation ensures significant family satisfaction. Structured and family-centered MDRs designed to address all aspects of patient care may answers all concerns family might have. The presence of entire ICU team reinforce families of the best care. CLINICAL IMPLICATIONS: Effective communication with patients' families is an important determinant of ICU outcome measures. Involvement of families either actively or passively in MDRs can be used as a key to obtain these parameters. Further studies are needed to objectively measure a family-centered patient care.Ref.: Roland P, et al - Visitation in critical care: process and outcomes of a performance improvement initiative. J Nurs Care Qual. 2001;15(2):18–26 DISCLOSURES: No relevant relationships by Samantha DeLuca, source=Web Response No relevant relationships by Sahar Fatima, source=Web Response No relevant relationships by Tina Lam, source=Web Response No relevant relationships by Iqbal Ratnani, source=Web Response Speaker/Speaker's Bureau relationship with Sunovian Please note: $5001 - $20000 Added 11/20/2017 by Salim Surani, source=Web Response, value=Honoraria Advisory Committee Member relationship with Astra Zeneca Please note: $5001 - $20000 Added 11/20/2017 by Salim Surani, source=Web Response, value=Consulting fee

Words Faithful to the Phenomenon

The article presents the developing of a tool aimed to analyze the decision-making (DM) processes in critical care contexts. It was developed in a study conducted through a phenomenological approach. By analyzing the discursive practice through which physicians in an intensive care unit (ICU) arrive at decisions, we construct a discursive profile of each ICU involved, to improve the ICU team members’ knowledge of the complexity of their DM processes. To do so, we develop a system of analysis capable of capturing discursive actions faithfully. Our method facilitates a system of analysis that highlights the role of the various discursive acts in conversational flow, starting from the needs in an ICU setting, which are spontaneously recognized from the data, to the almost simultaneous processes of description and understanding. This has led to the creation of a tool follows the phenomenological-grounded route.

Addressing Hand Hygiene Compliance in a Low-Resource Neonatal Intensive Care Unit: a Quality Improvement Project.

Our goal for this study was to quantify healthcare provider compliance with hand hygiene protocols and develop a conceptual framework for increasing hand hygiene compliance in a low-resource neonatal intensive care unit. We developed a 3-phase intervention that involved departmental discussion, audit, and follow-up action. A 4-month unobtrusive audit during night and day shifts was performed. The audit results were presented, and a conceptual framework of barriers to and solutions for increasing hand hygiene compliance was developed collectively. A total of 1308 hand hygiene opportunities were observed. Among 1227 planned patient contacts, hand-washing events (707 [58.6%]), hand rub events (442 [36%]), and missed hand hygiene (78 [6.4%]) events were observed. The missed hand hygiene rate was 20% during resuscitation. Missed hand hygiene opportunities occurred 3.2 times (95% confidence interval, 1.9-5.3 times) more often during resuscitation procedures than during planned contact and 6.14 times (95% confidence interval, 2.36-16.01 times) more often when providers moved between patients. Structural and process determinants of hand hygiene noncompliance were identified through a root-cause analysis in which all members of the neonatal intensive care unit team participated. The mean hand-washing duration was 40 seconds. In 83% of cases, drying hands after washing was neglected. Hand recontamination after hand-washing was seen in 77% of the cases. Washing up to elbow level was observed in 27% of hand-wash events. After departmental review of the study results, hand rubs were placed at each bassinet to address these missed opportunities. Hand hygiene was suboptimal during resuscitation procedures and between patient contacts. We developed a conceptual framework for improving hand hygiene through a root-cause analysis.

Improving Communication Between Surgery and Critical Care Teams: Beyond the Handover.

Structured communication tools for postoperative surgical handover to the intensive care unit (ICU) have shown promise, yet little work has addressed ongoing daily communication between the surgery and ICU teams thereafter. Evaluation of a novel, 2-part communication intervention between surgery and ICU teams focused on postoperative handover and ongoing daily communication. A mixed-methods, pre- and postintervention survey study was conducted in a closed quaternary medical-surgical ICU. Study participants (N = 112) included ICU physicians, nurses, allied health professionals, and physicians on the surgical team. The intervention consisted of a handover checklist completed postoperatively on arrival in the ICU and a 5-item communication tool completed daily by the surgical team. Satisfaction improved significantly in the following areas: postoperative handover communication (P < .001), daily communication (P = .001), understanding the postoperative plan (P < .001), initiation of deep vein thrombosis prophylaxis (P = .008), initiation of feeding (P = .009), and daily primary resident contact (P = .008). No significant improvement was seen in communication regarding disposition or overall improvement in patient safety risk from communication errors. A simple handover checklist improved health care practitioner satisfaction with communication during postoperative handover to the ICU. Concise daily communication tools are an appropriate option for improving ongoing communication between surgeons and the ICU team thereafter.

The Critical-Care Pain Observation Tool: A useful tool for pain assessment in intensive care units

Pain is a major concern in all intensive care units (ICUs). The proper assessment and management of pain is one of the main goals of patient care in ICUs. Improper evaluation of pain and its over or under treatment can cause significant problems in the process of patient management in ICU. Since most ICU patients are unable to communicate correctly with the ICU team and explain their level of pain, pain assessment can be challenging. Thus, several assessment tools for the evaluation of pain were developed, few of which were validated. Critical Care Pain Observation Tool is a valid and reliable instrument for pain assessment in different ICUs.

Improving Cardiac Surgery Outcomes by Using an Interdisciplinary Clinical Pathway.

A cardiothoracic intensive care unit (CTICU) team evaluated preoperative and postoperative processes to improve outcomes for cardiac surgery patients. The primary aim of this project was to streamline and improve care in the CTICU by implementing a new clinical pathway for patients undergoing coronary artery bypass graft or valve replacement procedures. We analyzed processes, communication, ventilator days, respiratory complications, patient mobility, presence of invasive catheters and lines, CTICU length of stay, and hospital-adjusted length of stay before and after we implemented the clinical pathway. This article outlines the methods we used to plan, implement, and assess the clinical pathway. Implementation of the clinical pathway successfully streamlined care, reduced variations in care, and improved health care quality and resource use.

Invited Commentary

Bleeding after cardiopulmonary bypass (CPB) is a complicated issue, especially in pediatric patients. Multiple age-related, CPB-related, and surgery-related variables come together to influence the amount of coagulopathy any given child will experience after CPB. Fortunately, with the advent of viscoelastic tests, thromboelastography (TEG) or rotational thromboelastometry (ROTEM), a path to identify and correct the coagulation abnormalities that are likely responsible is clearer now more than ever. These tests, performed on whole blood, allow for rapid assessment of clotting time, thrombocytopenia, hypofibrinogenemia, and fibrinolysis. Furthermore, they offer insight into platelet–fibrin interactions, fibrin polymerization, and possibly even thrombin generation. Studies that incorporate TEG and ROTEM testing into transfusion algorithms are beginning to emerge and report success in reducing allogeneic blood product exposure without an increase in postoperative bleeding [1Romlin B.S. Wahlander H. Berggren H. et al.Intraoperative thromboelastometry is associated with reduced transfusion prevalence in pediatric cardiac surgery.Anesth Analg. 2011; 112: 30-36Crossref PubMed Scopus (102) Google Scholar, 2Nakayama Y. Nakajima Y. Tanaka K.A. et al.Thromboelastometry-guided intraoperative haemostatic management reduces bleeding and red cell transfusion after paediatric cardiac surgery.Br J Anaesth. 2015; 114: 91-102Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar, 3Kane L.C. Woodward C.S. Husain S.A. Frei-Jones M.J. Thromboelastography—does it impact blood component transfusion in pediatric heart surgery?.J Surg Res. 2016; 200: 21-27Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar]. In this issue of The Annals of Thoracic Surgery, Emani and colleagues report their experience along this path [4Emani S. Sleeper L.A. Faraoni D. et al.Thromboelastography is associated with surrogates for bleeding after pediatric cardiac operations.Ann Thorac Surg. 2018; 106: 799-806Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar]. The authors perform a retrospective study in high-risk pediatric patients undergoing complex cardiac repairs to determine whether abnormal TEG parameters are associated with a surrogate endpoint for early postoperative bleeding. TEGs were obtained immediately after protamine administration (prior to the administration of post-CPB blood products) and upon arrival to the intensive care unit (ICU). To be clear, the TEGs were strictly observational and not clinically used to guide transfusion management. The authors define a composite endpoint for excessive bleeding, extended transfusion (ie, the need for blood products after the initial post-CPB transfusion of platelets), or the need for surgical reexploration. Of the 511 patients, 52% of patients with a maximum amplitude (MA) less than 45 mm reached the composite endpoint versus 31% with a MA greater than 45 mm (p < 0.001). In those patients who had an MA less than 45 mm, platelet transfusion intraoperatively was associated with a significant increase in median [IQR] MA (40.8 mm [37.5, 43] in the operating room versus 63.4 mm [56.2, 69.7] in the ICU; p < 0.001) and a lower incidence of the composite endpoint. Overall, MA less than 45 mm and neonatal age were independently associated with the composite endpoint. There are limitations to this study. The authors do not mention how it was decided to administer other products after the initial transfusion of platelets. Was there a defined process or was it subjectively decided by the anesthesia or surgery or ICU team? In addition, it is well known that neonates and small infants experience a significant dilutional hypofibrinogenemia after CPB, even when fresh frozen plasma is included in the circuit prime [5Hornykewycz S. Odegard K.C. Castro R.A. Zurakowski D. Pigula F. Dinardo J.A. Hemostatic consequences of a non-fresh or reconstituted whole blood small volume cardiopulmonary bypass prime in neonates and infants.Paediatr Anaesth. 2009; 19: 854-861Crossref PubMed Scopus (24) Google Scholar], and these patients often require fibrinogen repletion with cryoprecipitate. According to the authors’ defined composite endpoint, this would be considered “extended transfusion”. Thus, it is likely that the incidence they report for the composite endpoint is inflated. Nevertheless, studies similar to the one conducted by Emani and associates that explore the use of viscoelastic tests to guide transfusion algorithms are greatly needed. Such algorithms will likely vary according to institutions and their differing practices, and may even need to vary according to different target populations. In addition, the use of age-specific reference ranges and functional fibrinogen assays will further enhance our insight into the appropriate therapies. As reflected in the article by Emani and co-workers, we are beginning to make our way along this path. Thromboelastography Is Associated With Surrogates for Bleeding After Pediatric Cardiac OperationsThe Annals of Thoracic SurgeryVol. 106Issue 3PreviewPerioperative bleeding is a common complication in pediatric patients undergoing cardiac operation. Although thromboelastography (TEG) has been used in patients undergoing adult cardiac operation, limited data are available in pediatric patients. We hypothesize that TEG variables may be associated with surrogate end points for postoperative bleeding in pediatric patients undergoing complex cardiac operation. Full-Text PDF

The impact of the addition of nurse practitioners to surgical intensive care units: A retrospective cohort study

BackgroundDemand for surgical critical care is increasing, but work-hour restrictions on residents have affected many hospitals. Recently, the use of nurse practitioners (NPs) as providers in the intensive care unit (ICU) has expanded rapidly, although the impacts on quality of care have not been evaluated. ObjectivesTo compare the outcomes of critically ill surgical patients before and after the addition of NPs to the ICU team. MethodsWe conducted a retrospective cohort study in a Taiwanese surgical ICU. We compared the outcomes of patients admitted to ICU during the 2-year period before and after the addition of NPs to the ICU team. Patients admitted in the 1-year transition phase were excluded from comparisons. The primary endpoint was ICU mortality. Secondary endpoints included ICU length of stay and incidence of unplanned extubation. ResultsA total of 8747 patients were included in the study. For all eligible admissions, primary and secondary outcomes did not differ significantly between the two groups. For scheduled ICU admissions, ICU mortality was significantly lower after the addition of NPs (2.2% before vs. 1.1% after addition of NPs, p = 0.014). For unscheduled ICU admissions, ICU mortality did not differ significantly between the two groups. In the multivariate analysis, admission after the addition of NPs was associated with significantly reduced ICU mortality (odds ratio = 0.481; 95% confidence interval = 0.263–0.865; p = 0.015) among scheduled admissions. ConclusionIncorporating NPs in the ICU team was associated with improved outcomes in scheduled admissions to surgical ICU when compared with a traditional, resident-based team.

Postoperative Bedside Critical Care of Thoracic Surgery Patients.

Postoperative Bedside Critical Care of Thoracic Surgery Patients.

Collaboration between intensive care unit physicians and physiatrists with severe brain injured patients: A French practice survey

The role of physiatrists with severe brain injured patients and intensive care unit (ICU) teams is often pointed out but remains still partly unknown. We aimed at evaluating, from ICU physicians and physiatrists’ points of view, the characteristics of interventions of physiatrists in ICU (especially concerning end-of-life decisions) and their possibilities of development. A national study using an online survey was performed between January and September 2017, sent to ICU physicians (n = 181 answers) and physiatrists (n = 35) dealing with severe brain injured patients. A large majority of ICU physicians (72%) collaborated with physiatrists in their practice, most often non-routinely (78%) on a weekly (30.5%) or monthly basis (36.6%). Physiatrists mainly helped ICU teams in post-ICU orientation of patients (85%), but also in clinical assessment (55%). Considering end-of-life decisions, solicitations of physiatrists were rare in the ICU physicians’ point of view (47% on an annual basis), but more frequent in the physiatrists sample (monthly or bimonthly = 48%), and was considered as beneficial or necessary for 70% of ICU physicians. Physiatrists and ICU physicians gave the same importance in the end-of-life decision process to clinical and paraclinical examinations, but not to patients socio-economic data. Physiatrists mainly conceived their interventions in end-of-life decisions in complex cases (56%), their legitimacy in this domain was rated as 6.5/10 (10 = high legitimacy) by ICU physicians. Improving the collaboration between both specialties was a common desire (of 68% of physiatrists and 88% of ICU physicians). Physiatrists have a specific and important role to play with severe brain injured patients in ICU, in various domains of action including particularly orientation, assessment or end-of-life decision process. This role should be promoted and better valorized.

Integrating a Mobility Champion in the Intensive Care Unit.

In recent years, early progressive mobilization programs have become mainstays in intensive care units (ICUs). Significant evidence exists that early mobility programs decrease length of stay, reduce time on the ventilator, and decrease the development of delirium in ICU patients. Yet, current literature still describes many barriers to performing early mobility, such as the time required, staffing pressures, and increased workload. Our critical care leaders found that defining and implementing a dedicated mobility champion team member was successful in improving the effectiveness of our early mobility program. This article describes how to define the mobility champion role, consider options for the person in the role, and integrate this new role into the ICU team.

From breaking point to breakthrough during the ICU stay: A qualitative study of family members' experiences of long-term intensive care patients' pathways towards survival.

To explore family members' experiences of long-term intensive care unit (ICU) patients' pathways towards survival and to highlight family members' efforts to promote the patient's health during the ICU stay. Although considerable research has been devoted to the substantial burden of long-term ICU patients, less attention has been paid to health-promoting factors that facilitate patients' health and survival during ICU stays. Support from family members can improve patient outcome. However, there is little knowledge of the specific contributions provided by family members. A hermeneutic phenomenological approach, within the context of Antonovsky's salutogenic theory and Merleau-Ponty's phenomenology of the body, involving the body as the fundament of experience and understanding. In-depth qualitative interviews. Thirteen family members of long-term ICU patients were interviewed once, at six to 18months after ICU discharge. The consolidated criteria for reporting qualitative research were used. Three themes were identified: (i) A body at a breaking point; (ii) family members' presence; and (iii) breaking through. In the perspective of the family members, their beloved ones were at a breaking point between life and death. The family's presence was significantly health promoting, demonstrating and communicating love and sensitivity. Moreover, family members' understanding of the patient's unique characteristics and personality was crucial to the patient's experience of being understood, recognised and acknowledged. Inner strength represented a life force capable of moving the patient from the breaking point towards a breakthrough towards life. Family members purposely used their knowledge about the patient to trigger, nurture and release the patient's inner strength. Family presence helps to trigger, arouse and release a patient's inner strength, representing important health-promoting factors facilitating patients' health and survival during an ICU stay. Insights into the unique and vital health-promoting influence of family participation indicate the responsibility of the ICU team to provide support for families.

A Randomized Trial of a Family-Support Intervention in Intensive Care Units

BackgroundSurrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients’ preferences.MethodsWe conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates’ mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates’ mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician–family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay.ResultsA total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates’ mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, −0.34; 95% confidence interval [CI], −1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, −1.66 to 3.47; P=0.49). The surrogates’ mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, −0.15; 95% CI, −0.26 to −0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001).ConclusionsAmong critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates’ burden of psychological symptoms, but the surrogates’ ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care. (Funded by the UPMC Health System and the Greenwall Foundation; PARTNER ClinicalTrials.gov number, NCT01844492.)