Blogger: Tom Heaton
Trauma and stress in ICU: can we make an impact?
The session was opened by Dorothy Wade, a health psychologist who has significant experience working with critical care patients. She discussed some of the very important psychological problems experienced by patients both during and after their stay in an intensive care unit.
- Psychological stress very common after ITU. Often quite severe problems; depression, anxiety, PTSD.
- It’s a scary place with scary equipment. Often a lot of distress from the surrounding patients – screaming, dying, grieving relatives.
- Multiple scary interventions – psychoactive drugs.
- Affects 50-80% – confusion, delusions, hallucinations.
- Many of these problems can follow patients home – persisting hallucinations and delusions. More common to be in the form of flashbacks.
- Can affect quality of life; cognitive impairment in 11-62%, psychological distress (anxiety up to 34%), physical impairment.
- Risk factors fairly well known; benzodiazepines, ventilation, number of procedures.
- Acute stress the most important predictor of poor psychological outcome.
- How can we help?
- Modify the environment e.g. minimise loud sounds, frightening sights.
- Avoid psychoactive drugs. Involve families.
- Helping patients to communicate – find a way. Often not given a high priority and yet this is the part patients really want.
- Encourage talking afterwards.
- Assess patients – IPAT one option – intensive care psychological assessment tool
- Pyschologists should be key members of the ICM MDT – They can do psychology ward rounds (advice on drugs, help keep patients informed), follow up clinic, support staff.
- However, generally quite poor quality evidence on non-pharmacological interventions.
- POPPI study and CALMS study are big RCTS investigating interventions – results eagerly awaited.
- Identifying risk factors for PTSD after critical care – https://www.uclh.nhs.uk/OurServices/Consultants/Documents/Dorothy%20Wade%20profile%20documents/PTSDpubrev.pdf
- Critical Care Medicine. Risk factors for psychological morbidity – http://www.ccforum.com/content/16/5/R192
- Critical Care. Detecting acute distress. http://www.ccforum.com/content/18/5/519
- Rehabilitation after critical illness guidance – https://www.nice.org.uk/guidance/cg83
Changing the conversation in ICU
Judith Nelson continued this theme by providing a thought provoking talk on how we should be perhaps changing the areas we are focusing on in our current practice.
- Perhaps we need to change focus to survivorship, emotion and the team rather than just death, cognition and individuals.
- There is a difference between survival and complete recovery – surviving ITU affects people.
- Prognosis making is now more perilous then ever; moving target, mistaken prediction, magic number, mean clinician, misplace emphasis (the 5 M’s)
- Moving target. Mortality is dropping e.g in sepsis and ARDS. How can we make good prognoses?
- Note ‘Power and limitations of daily prognostication’ study (ref below) – actually quite bad at this – 50% of those predicted to die left hospital.
- Magic numbers – we often want numbers that aren’t going to help us – is a probability of survival going to change patient or family attitude?
- Mean clinician problem – Evidence that being negative or pessimistic affects our patient relationship – viewed as less compassionate.
- Misplaced emphasis – with increased uncertainty we move more towards value based judgement.
- We talk a lot about the facts – but we’re often not always set up to manage facts. We have a large amount of hard-wiring that prioritises our emotional response. We need to recognise this in our patients, their families and our self.
- How do we deal with this? – empathy – try and allow the emotional storm to settle and cognitive ‘rational’ processes to come back to the fore.
- Critical Care Medicine. Improving long term outcomes after discharge from ITU – http://www.ncbi.nlm.nih.gov/pubmed/21946660
- Critical Care Medicine. Power and limitation of daily prognostication – http://www.ncbi.nlm.nih.gov/pubmed/21946660
- Patient perception of physician compassion – http://oncology.jamanetwork.com/article.aspx?articleid=2120917
- Annals of internal medicine. Survivorship will be the defining challenge of critical care – http://annals.org/article.aspx?articleid=745945
- After a diagnosis, wishing for a magic number – http://well.blogs.nytimes.com/2011/03/21/after-a-diagnosis-wishing-for-a-magic-number/?_r=0
The impact of ICU environment and design
Jozef Kesecioglu closed the session with a great description of how he was involved in the design of a new ITU. He recapped the history of how the ITU idea had come into being, from the Nightingale wards through to the polio epidemic, noting how their initial focus was in the improvement of physical illness.
- Main focus of the ITU was the improvement of illness – focus on pathology.
- We are now increasingly identifying the importance of the patient’s mental health, and indeed that of the staff.
- So how do we build these factors into building a new ITU?
- Firstly define a vision – what do you want to achieve?
- They interviewed patients and families of patients, then created a mock up and actually tested function.
- Patient centred care dictates design – functionality and safety being defining concepts.
- Private patient rooms being the standard – many benefits – quiet, infection control, fewer medication errors, improved communication, privacy.
- Natural light – important for normal biology – day-night cycle. Reduced agitation, depression, analgesia needs.
- Patient needs to feel at home – chairs, clock. Equipment all behind patient – out of view.
- Needs of the family also considered – relatives room with internet, TV, phone, own café, outside space.
- Also 24 hour visiting and beds for family. Actually reduced the concentration of relatives in the unit as not all cramming in during visiting hours.
- All these changes showed a lot of benefit in satisfaction. Felt it also improved interpersonal features – e.g. staff more helpful, though no change in staff.
- Some suggestion that the duration of delirium was shorter in the new environment, even if the incidence wasn’t.
- Some aesthetic factors will age, but the benefits of daylight, privacy and quiet will not.
- Clearly not feasible to just go and build a new ITU, but the process wasn’t more expensive than it would have been – just more thought put into the design.
- Improving the patient’s environment – https://www.researchgate.net/publication/269776078_Improving_the_patients_environment_the_ideal_intensive_care_unit