Journal of the Intensive Care Society最新文献

Background: The decision to admit patients to the intensive care unit (ICU) is complex. Structuring the decision-making process may be beneficial to patients and decision-makers alike. The aim of this study was to investigate the feasibility and impact of a brief training intervention on ICU treatment escalation decisions using the Warwick model- a structured decision-making framework for treatment escalation decisions.

Methods: Treatment escalation decisions were assessed using Objective Structured Clinical Examination-style scenarios. Participants were ICU and anaesthetic registrars with experience of making ICU admission decisions. Participants completed one scenario, followed by training with the decision-making framework and subsequently a second scenario. Decision-making data was collected using checklists, note entries and post-scenario questionnaires.

Results: Twelve participants were enrolled. Brief decision-making training was successfully delivered during the normal ICU working day. Following training participants demonstrated greater evidence of balancing the burdens and benefits of treatment escalation. On visual analogue scales of 0-10, participants felt better trained to make treatment escalation decisions (4.9 vs 6.8, p = 0.017) and felt their decision-making was more structured (4.7 vs 8.1, p = 0.017).Overall, participants provided positive feedback and reported feeling more prepared for the task of making treatment escalation decisions.

Conclusion: Our findings suggest that a brief training intervention is a feasible way to improve the decision-making process by improving decision-making structure, reasoning and documentation. Training was implemented successfully, acceptable to participants and participants were able to apply their learning. Further studies of regional and national cohorts are needed to determine if training benefit is sustained and generalisable.

Background: Adverse sequelae are common in survivors of critical illness. Physical, psychological and cognitive impairments can affect quality of life for years after the original insult. Driving is an advanced task reliant on complex physical and cognitive functioning. Driving represents a positive recovery milestone. Little is currently known about the driving habits of critical care survivors. The aim of this study was to explore the driving practices of individuals after critical illness. Methods: A purpose-designed questionnaire was distributed to driving licence holders attending critical care recovery clinic. Results: A response rate of 90% was achieved. 43 respondents declared their intention to resume driving. Two respondents had surrendered their licence on medical grounds. 68% had resumed driving by 3 months, 77% by 6 months, and 84% by 1 year. The median interval (range) between critical care discharge and resumption of driving was 8 weeks (1-52 weeks). Psychological, physical and cognitive barriers were cited by respondents as barriers to driving resumption. Eight themes regarding driving resumption were identified from the framework analysis under three core domains and included: psychological/cognitive impact on ability to drive (Emotional readiness and anxiety; Confidence; Intrinsic motivation; Concentration), physical ability to drive (Weakness and fatigue; Physical recovery), and supportive care and information needs to resume driving (Information/advice; Timescales). Conclusion: This study demonstrates that resumption of driving following critical illness is substantially delayed. Qualitative analysis identified potentially modifiable barriers to driving resumption.

Background: To investigate the impact of physical activity interventions, including early mobilisation, on delirium outcomes in critically ill patients.

Methods: Electronic database literature searches were conducted, and studies were selected based on pre-specified eligibility criteria. Cochrane Risk of Bias-2 and Risk Of Bias In Non-randomised Studies-of Interventions quality assessment tools were utilised. Grading of Recommendations, Assessment, Development and Evaluations was used to assess levels of evidence for delirium outcomes. The study was prospectively registered on PROSPERO (CRD42020210872).

Results: Twelve studies were included; ten randomised controlled trials one observational case-matched study and one before-after quality improvement study. Only five of the included randomised controlled trial studies were judged to be at low risk of bias, with all others, including both non-randomised controlled trials deemed to be at high or moderate risk. The pooled relative risk for incidence was 0.85 (0.62-1.17) which was not statistically significant in favour of physical activity interventions. Narrative synthesis for effect on duration of delirium found favour towards physical activity interventions reducing delirium duration with median differences ranging from 0 to 2 days in three comparative studies. Studies comparing varying intervention intensities showed positive outcomes in favour of greater intensity. Overall levels of evidence were low quality.

Conclusions: Currently there is insufficient evidence to recommend physical activity as a stand-alone intervention to reduce delirium in Intensive Care Units. Physical activity intervention intensity may impact on delirium outcomes, but a lack of high-quality studies limits the current evidence base.

Good glycaemic control confers an outcome benefit in both diabetic and non-diabetic critically unwell patients. Critically unwell patients receiving intravenous insulin in the intensive care unit (ICU) require hourly glucose monitoring. This brief communication highlights the impact of the introduction of the FreeStyle Libre glucose monitor, a form of continuous glucose monitoring, on the frequency of glucose recordings in patients receiving intravenous insulin in the ICU at York Teaching Hospital NHS Foundation Trust.

Introduction: The global pandemic caused by novel Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has led to an unprecedented demand on critical care resources. The United Kingdom experienced its 'first wave' of Coronavirus-19 (Covid-19) disease in Spring 2020. Critical care units had to make major changes to their working practices in a short space of time and faced multiple challenges in doing so, including the challenge of caring for patients in multiple organ failure secondary to Covid-19 infection in the absence of an established evidence base of best practice. We undertook a qualitative investigation of the personal and professional challenges faced by critical care consultants in one Scottish health board in acquiring and evaluating information to guide clinical decision making during the first wave of the SARS-CoV-2 pandemic.

Methods: Critical care consultants in NHS Lothian working in critical care from March to May 2020 were eligible to participate in the study. Participants were invited to take part in a one-to-one semi structured interview conducted using Microsoft Teams videoconferencing software. Reflexive thematic analysis was used as the method for data analysis using qualitative research methodology informed by a subtle realist position.

Results: Analysis of the interview data generated the following themes: The Knowledge Gap; Trust in Information; and Implications for Practice. Illustrative quotes are presented in the text and thematic tables.

Discussion: This study explored the experiences of critical care consultant physicians in acquiring and evaluating information to guide clinical decision making during the first wave of the SARS CoV2 pandemic. This study revealed that clinicians were profoundly affected by the pandemic and the ways in which it changed how they could access information to guide clinical decision making. The paucity of reliable information on SARS-CoV-2 posed a significant threat to the clinical confidence of participants. Two strategies were adopted to ease mounting pressures - an organised approach to data collection and the establishment of a local community of collaborative decision-making. These findings contribute to the wider literature by describing health care professionals' experiences in unprecedented times and could inform recommendations for future clinical practice. This could include governance around responsible information sharing in professional instant messaging groups, and medical journal guidelines on suspension of usual peer review and other quality assurance processes during pandemics.

Communication difficulties and their effects on patients who are mechanically ventilated are commonly reported and well described. The possibility of restoring speech for patients has obvious benefits, not only for meeting patient's immediate needs, but for helping them to re-engage in relationships and participate meaningfully in their recovery and rehabilitation. This opinion piece by a group of United Kingdom (UK) based Speech and Language Therapy experts working in critical care describes the various ways by which a patient's own voice can be restored. Common barriers to using different techniques and potential solutions are explored. We therefore hope that this will encourage intensive care unit (ICU) multi-disciplinary teams to advocate and facilitate early verbal communication in these patients.

Purpose: The use of coercion, in a clinical context as imposing a measure against a patient's opposition or declared will, can occur in various forms in intensive care units (ICU). One prime example of a formal coercive measure in the ICU is the use of restraints, which are applied for patients' own safety. Through a database search, we sought to evaluate patient experiences related to coercive measures.

Results: For this scoping review, clinical databases were searched for qualitative studies. A total of nine were identified that fulfilled the inclusion and the CASP criteria. Common themes emerging from the studies on patient experiences included communication issues, delirium, and emotional reactions. Statements from patients revealed feelings of compromised autonomy and dignity that came with a loss of control. Physical restraints were only one concrete manifestation of formal coercion as perceived by patients in the ICU setting.

Conclusion: There are few qualitative studies focusing on patient experiences of formal coercive measures in the ICU. In addition to the experience of restricted physical movement, the perception of loss of control, loss of dignity, and loss of autonomy suggests that restraining measures are just one element in a setting that may be perceived as informal coercion.

A 48-year-old gentleman who had recently commenced chemotherapy for diffuse B-cell lymphoma was admitted to hospital with nausea and generalised weakness. He developed abdominal pain and oliguric acute kidney injury with multiple electrolyte derangements and was transferred to the intensive care unit (ICU). His condition deteriorated, requiring endotracheal intubation and renal replacement therapy (RRT). Tumour lysis syndrome (TLS) is a common and life-threatening complication of chemotherapy and represents an oncological emergency. TLS affects multiple organ systems and is best managed in the ICU with closer monitoring of fluid balance, serum electrolytes, cardiorespiratory and renal function. TLS patients may go on to require mechanical ventilation and RRT. TLS patients require input from a large multidisciplinary team of clinicians and allied health professionals.