Thematic analysis of intensive care unit diaries kept by staff: insights for caring.

OBJECTIVE: To explore recurrent themes in diaries kept by intensive care unit (ICU) staff during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: Qualitative study. SETTING: Two ICUs in a tertiary level hospital (Milan, Italy) from January to December 2021. METHODS: ICU staff members wrote a digital diary while caring for adult patients hospitalized in the intensive care unit for >48 hours. A thematic analysis was performed. FINDINGS: Diary entries described what happened and expressed emotions. Thematic analysis of 518 entries gleaned from 48 diaries identified four themes (plus ten subthemes): Presenting (Places and people; Diary project), Intensive Care Unit Stay (Clinical events; What the patient does; Patient support), Outside the Hospital (Family and topical events; The weather), Feelings and Thoughts (Encouragement and wishes; Farewell; Considerations). CONCLUSION: The themes were similar to published findings. They offer insight into care in an intensive care unit during a pandemic, with scarce resources and no family visitors permitted, reflecting on the patient as a person and on daily care. The staff wrote farewell entries to dying patients even though no one would read them. IMPLICATIONS FOR CLINICAL PRACTICE: The implementation of digital diaries kept by intensive care unit staff is feasible even during the COVID-19 pandemic. Diaries kept by staff can provide a tool to humanize critical care. Staff can improve their work by reflecting on diary records.

The end of life of patients with COVID-19 in intensive care unit and the stress level on their family members: A cross-sectional study.

BACKGROUND: During the Coronavirus disease 2019 (COVID-19) pandemic, hospital visits were suspended and video calls were offered to connect patients with their family members, especially toward the end of life (EoL). AIM: The primary aim was to describe EoL care for COVID-19 patients dying in an intensive care unit (ICU). The secondary aim was to explore whether making video calls and allowing visits was associated with lower death-related stress in family members. DESIGN: Single centre cross-sectional study. The setting was the ICU of a COVID-19 center in northern Italy, during the first year of the pandemic. Data on patients who died in the ICU were collected; death-related stress on their family members was measured using the Impact of Event Scale-Revised (IES-R). The statistical association was tested by means of logistic regression. RESULTS: The study sample included 70 patients and 56 family members. All patients died with mechanical ventilation, hydration, nutrition, analgesia and sedation ongoing. Resuscitation procedures were performed in 5/70 patients (7.1%). Only 6/56 (10.7%) of the family members interviewed had visited their loved ones in the ICU and 28/56 (50%) had made a video call. EoL video calls were judged useful by 53/56 family members (94.6%) but all (56/56, 100%) wished they could have visited the patient. High-stress levels were found in 38/56 family members (67.9%), regardless of whether they were allowed ICU access or made a video call. Compared with other degrees of kinship, patients' offspring were less likely to show a positive IES-R score (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.05 to 0.89). CONCLUSIONS: During the first year of the COVID-19 pandemic, patients died without their family members at the bedside while on life-sustaining treatment. Stress levels were high in most family members, especially in patients' spouses. Video calls or ICU visits were judged favourably by family members but insufficient to alleviate death-related stress. RELEVANCE FOR CLINICAL PRACTICE: During a pandemic, ICU access by patients' family members should be considered, particularly as the time of death approaches. Although generally appreciated by family members, EoL video calls should be arranged together with other measures to alleviate death-related stress, especially for the patient's spouse.

Association of ventilator-free days with respiratory physiotherapy in critically ill patients with Coronavirus Disease 2019 (COVID-19) during the first pandemic wave. A propensity score-weighted analysis.

Background: Respiratory physiotherapy is reported as safe and feasible in mechanically ventilated patients with severe Coronavirus Disease (COVID-19) admitted to Intensive Care Unit (ICU), but the short-term benefits remain unclear. Methods: We performed a retrospective observational study in four ICUs in Northern Italy. All patients with COVID-19 admitted to ICU and under invasive mechanical ventilation (MV) between March 1st and May 30th, 2020, were enrolled into the study. Overlap weighting based on the propensity score was used to adjust for confounding in the comparison of patients who had or had not been treated by physiotherapists. The primary outcome was the number of days alive and ventilator-free (VFDs). The secondary outcomes were arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio (P/F) at ICU discharge, ICU length of stay, ICU and hospital mortality, and survival at 90 days. The trial protocol was registered on clinicaltrials.gov (NCT05067907). Results: A total of 317 patients were included in the analysis. The median VFDs was 18 days [interquartile range (IQR) 10; 24] in patients performing physiotherapy and 21 days (IQR 0; 26) in the group without physiotherapy [incidence rate ratio (IRR) 0.86, 95% confidence interval (CI): 0.78; 0.95]. The chance of 0 VFDs was lower for patients treated by physiotherapists compared to those who were not [odds ratio (OR) = 0.36, 95% CI: 0.18-0.71]. Survival at 90 days was 96.0% in the physiotherapy group and 70.6% in patients not performing physiotherapy [hazard ratio (HR) = 0.14, 95% CI: 0.03-0.71]. Number of VFDs was not associated with body mass index (BMI), sex, or P/F at ICU admission for individuals with at least 1 day off the ventilator. Conclusion: In patients with COVID-19 admitted to ICU during the first pandemic wave and treated by physiotherapists, the number of days alive and free from MV was lower compared to patients who did not perform respiratory physiotherapy. Survival at 90 days in the physiotherapy group was greater compared to no physiotherapy. These findings may be the starting point for further investigation in this setting.

Time to active sitting position: One-year findings from a temporary COVID-19 intensive care unit.

OBJECTIVE: To investigate the association between time to active sitting position and clinical features in people with COVID-19 admitted to intensive care unit (ICU) and referred to physiotherapists. METHOD: Prospective study conducted in the largest temporary ICU in Lombardy (Italy) between April 2020 and June 2021. All individuals with COVID-19 who received physiotherapy were included. Multivariable Cox proportional hazard model was fitted to explore the statistical association between active sitting position and characteristics of patients referred to physiotherapists, also accounting for the different multidisciplinary teams responsible for patients. RESULTS: 284 individuals over 478 (59.4%) had access to physiotherapy, which was performed for a median of 8 days, without difference between multidisciplinary teams (P = 0.446). The active sitting position was reached after a median of 18 (IQR: 10.0-32.0) days. Sex was the only characteristic associated with the time to active sitting position, with males showing a reduced hazard by a factor of 0.65 (95% CI: 0.48-0.87; P = 0.0042) compared to females. At ICU discharge, nearly 50% individuals increased Manchester Mobility Score by 3 points. During physiotherapy no major adverse event was recorded. CONCLUSION: Individuals with COVID-19 take long time to reach active sitting position in ICU, with males requiring longer rehabilitation than females.

Muscle strength and functional outcome after prone positioning in COVID-19 ICU survivors.

OBJECTIVE: To evaluate the muscle strength and functional level of patients discharged from intensive care unit (ICU) in relation to the swimmer position as a nurse intervention during pronation. METHODS: Prospective study conducted in the hub COVID-19 center in Milan (Italy), between March and June 2020. All patients with COVID-19 discharged alive from ICU who received invasive mechanical ventilation were included. Forward continuation ratio model was fitted to explore the statistical association between muscle strength grades and body positioning during ICU stay. RESULTS: Over the 128 patients admitted to ICU, 87 patients were discharged alive from ICU, with available follow-up measures at hospital discharge. Thirty-four patients (39.1%) were treated with prone positioning as rescue therapy, for a total of 106 pronation cycles with a median duration of 72 (IQR 60-83) hours. Prone positioning did not influence the odds of showing particular level of muscle strength, in any of the evaluated districts, namely shoulder (OR 1.34, 95%CI:0.61-2.97), elbow (OR 1.10, 95%CI:0.45-2.68) and wrist (OR 0.97, 95%CI:0.58-1.63). Only in the shoulder district, age showed evidence of association with strength (OR 1.06, 95%CI:1.02-1.10), affecting people as they get older. No significant sequalae related to swimmer position were reported by physiotherapists or nurses. CONCLUSION: Swimmer position adopted during prone ventilation is not associated with worse upper limb strength or poor mobility level in COVID-19 survivors after hospital discharge.

Complications of prone positioning in patients with COVID-19: A cross-sectional study.

OBJECTIVE: To determine the prevalence of complications in patients with COVID-19 undergone prone positioning, focusing on the development of prone-related pressure ulcers. METHODS: Cross-sectional study conducted in the hub COVID-19 centre in Milan (Italy), between March and June 2020. All patients with COVID-19 admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning were included. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. RESULTS: A total of 219 proning cycles were performed on 63 patients, aged 57.6 (10.8) and predominantly obese males (66.7%). The main complications recorded were: prone-related pressure ulcers (30.2%), bleeding (25.4%) and medical device displacement (12.7%), even if no unplanned extubation was recorded. The majority of patients (17.5%) experienced bleeding of upper airways. Only 15 prone positioning cycles (6.8%) were interrupted, requiring staff to roll the patient back in the supine position. The likelihood of pressure ulcers development was independently associated with the duration of prone positioning, once adjusting for age, hypoxemic level, and nutritional status (OR 1.9, 95%CI 1.04-3.6). CONCLUSION: The use of prone positioning in patients with COVID-19 was a safe and feasible treatment, also in obese patients, who might deserve more surveillance and active prevention by intensive care unit staff.

Pattern of Visits in a Metropolitan Emergency Department in Lombardia (Italy): January 2019-December 2020.

During the Coronavirus disease 2019 (COVID-19), a general decrease in the presentations to emergency departments (ED) was reported. However, we suspect that there was a lower number but an unchanged pattern of ED visits for urgent conditions in 2020 compared to 2019. This retrospective study assessed the change in the number of presentations in the ED of a tertiary level university hospital in Milano (Lombardia, Italy). Compared to 2019, a significant drop in ED presentations occurred (-46.4%), and we recorded a -15.7% difference in the proportion of patients admitted with white codes. The pattern of hourly presentations to the ED was unchanged, with overcrowding during the working daytime. COVID-19 changed ED flows, likely causing an overall reduction in the number of deferrable conditions. However, the pattern associated with urgent conditions did not change abruptly in 2020.

Facing COVID-19 Pandemic in a Tertiary Hospital in Milan: Prevalence of Burnout in Nursing Staff Working in Sub-Intensive Care Units.

In early March 2020, Italy became the epicenter of the Coronavirus Disease 2019 (COVID-19) pandemic in Europe. A different organization of hospital units was required to take care of patients affected by acute respiratory failure caused by COVID-19. This study aimed to evaluate the prevalence of burnout in two sub-intensive care units (SICUs) of the COVID-19 hub center of the Lombardia region in Milan (Italy). All nurses and healthcare assistants working in the SICUs during June 2020 were included in the study. Burnout was assessed via the Maslach Burnout Inventory questionnaire. One hundred and five (84%) SICU staff participated in the study. The prevalence of high burnout for nurses and healthcare assistants was 61.9% for emotional exhaustion, 47.6% for depersonalization and 34.3% for personal accomplishment. Depersonalization was significantly more frequent in younger nurses (p = 0.009). Nurses were 4.5 times more likely to have burnout than healthcare assistants. Burnout was a common condition among healthcare workers operating in SICUs during the pandemic. Urgent actions are needed, especially for nurses, as well as preventive strategies for future pandemic scenarios.

Nursing Management of Prone Positioning in Patients With COVID-19.

BACKGROUND: At the height of the coronavirus disease 2019 (COVID-19) pandemic, Italy had the highest number of deaths in Europe; most occurred in the Lombardy region. Up to 4% of patients with COVID-19 required admission to an intensive care unit because they developed a critical illness (eg, acute respiratory distress syndrome). Numerous patients with acute respiratory distress syndrome who had been admitted to the intensive care unit required rescue therapy like prone positioning. OBJECTIVE: To describe the respiratory management of and the extensive use of prone positioning in patients with COVID-19 at the intensive care unit hub in Lombardy, Italy. METHODS: A total of 89 patients (67% male; median age, 59 years [range, 23-80 years]) with confirmed COVID-19 who were admitted between February 23 and March 31, 2020, were enrolled in this quality improvement project. RESULTS: Endotracheal intubation was required in 86 patients (97%). Prone positioning was used as rescue therapy in 43 (48%) patients. Significantly more younger patients (age ≤ 59 years) were discharged alive (43 of 48 [90%]) than were older patients (age ≥ 60 years; 26 of 41 [63%]; P < .005). Among the 43 patients treated with prone ventilation, 15 (35% [95% CI, 21%-51%]) died in the intensive care unit, of which 10 (67%; P < .001) were older patients. CONCLUSIONS: Prone positioning is one strategy available for treating acute respiratory distress syndrome in patients with COVID-19. During this pandemic, prone positioning can be used extensively as rescue therapy, per a specific protocol, in intensive care units.

Using video presentation to recruit healthcare workers during COVID-19 pandemic.

During COVID-19 pandemic, the recruitment of new personnel was necessary to guarantee an adequate healthcare level to all patients affected by SARS-CoV-2 virus. In order to deal with the sanitary emergency, unusual selection procedures have been adopted inside the public health system by searching for new healthcare personnel. The recruitment of new candidates with a short self-introduction was very effective and permitted to select 65 nurses.