Healthcare workers' experiences of patient safety in the intensive care unit during the COVID-19 pandemic: A multicentre qualitative study.

AIM: To describe healthcare workers' experiences of preconditions and patient safety risks in intensive care units during the COVID-19 pandemic. BACKGROUND: Healthcare workers' ability to adapt to changing conditions is crucial to promote patient safety. During the COVID-19 pandemic, healthcare workers' capacity to maintain safe care was challenged and a more in-depth understanding on frontline experiences of patient safety is needed. DESIGN: A qualitative descriptive design. METHODS: Individual interviews were conducted with 29 healthcare workers (nurses, physicians, nurse assistants and physiotherapists) from three Swedish hospitals directly involved in intensive care of COVID-19 patients. Data were analysed with inductive content analysis. Reporting followed the COREQ checklist. RESULTS: Three categories were identified. Hazardous changes in working conditions describes patient safety challenges associated with the extreme workload with high stress level. Imperative adaptations induced by changed preconditions for patient safety which include descriptions of safety risks following adaptations related to temporary intensive care facilities, handling shortage of medical equipment and deviations from routines. Safety risks triggered by reorganisation of care describe how the diluted skill-mix and team disruptions exposed patients to safety risks, and that safety performance mostly relied on individual healthcare worker's responsibility. CONCLUSIONS: The study suggests that healthcare workers experienced an increase in patient safety risks during the COVID-19 pandemic mainly because the extremely high workload, imperative adaptations, and reorganisation of care regarding skill-mix and teamwork. Patient safety performance relied on the individuals' adaptability and responsibility rather than on system-based safety. RELEVANCE TO CLINICAL PRACTICE: This study provides insights on how healthcare workers' experiences can be used as a source of information for recognition of patient safety risks. To improve detection of safety risks during future crises, guidelines on how to approach safety from a system perspective must include healthcare workers' perceptions on safety risks. PATIENT AND PUBLIC CONTRIBUTION: None in the conceptualisation or design of the study.

Intensive care nurses' lived experience of altruism and sacrifices during the Covid-19 pandemic: A phenomenological study.

AIM: The aim of this study was to understand the lived experience of altruism and sacrifices among Swedish nurses working in intensive care units (ICU) during the COVID-19 pandemic. DESIGN: This was a descriptive phenomenological study. METHODS: The study was conducted between June 2020 and March 2021 and included 20 nurses who were directly involved in the ICU care of COVID-19 patients in Sweden during the pandemic. The text transcripts were analysed using Malterud's Systematic Text Condensation. FINDINGS: The analysis revealed four themes. The work situation changed from 1 day to another-the nurses were brutally confronted with a new and highly demanding situation. Adapting to the chaotic situation-despite fear, anguish and exhaustion, the nurses adapted to the new premises. They shouldered the moral responsibility and responded to the needs of the patients and the health care system since they had the competence. Being confronted with ethical and moral challenges-the nurses were overwhelmed by feelings of helplessness and inadequacy because despite how hard they worked, they were still unable to provide care with dignity and of acceptable quality. The importance of supporting each other-collegiality was fundamental to the nurses' ability to cope with the situation. CONCLUSIONS: Taken together, being exposed to a constantly changing situation, facing the anguish and misery of patients, families, and colleagues, and being confronted with a conflict between the moral obligation to provide care of high quality and the possibility to fulfil this commitment resulted in suffering among the nurses. Collegial back-up and a supportive culture within the caring team were important for the nurses' endurance. IMPACT: The study contributes an understanding of nurses' lived experience of working during the COVID-19 pandemic and highlights the importance of protecting and preparing nurses and nursing organisation for potential future crises.

Family members' experiences of COVID-19 visiting restrictions in the intensive care unit-A qualitative study.

OBJECTIVE: To describe how family members of critically ill patients experienced the COVID-19 visiting restrictions in Sweden. BACKGROUND: In Sweden, the response to COVID-19 was less invasive than in many other countries. However, some visiting restrictions were introduced for intensive care units, with local variations. Although there is a growing body of literature regarding healthcare professionals' and family caregivers' perspectives on visiting restriction policies, there may be inter-country differences, which remain to be elucidated. DESIGN: This study has a qualitative descriptive design. Focus group interviews with 14 family members of patients treated for severe COVID-19 infection were conducted. The interviews took place via digital meetings during the months after the patients' hospital discharge. Qualitative content analysis was used to interpret the interview transcripts. Reporting of the study followed the COREQ checklist. RESULTS: Two categories-dealing with uncertainty and being involved at a distance-described family members' experiences of coping with visiting restrictions during the COVID-19 pandemic. These restrictions were found to reduce family members' ability to cope with the situation. Communication via telephone or video calls to maintain contact was appreciated but could not replace the importance of personal contact. CONCLUSIONS: Family members perceived that the visiting restriction routines in place during the COVID-19 pandemic negatively influenced their ability to cope with the situation and to achieve realistic expectations of the patients' needs when they returned home. RELEVANCE TO CLINICAL PRACTICE: This study suggests that, during the COVID-19 pandemic, the visiting restrictions were experienced negatively by family members and specific family-centred care guidelines need to be developed for use during crises, including the possibility of regular family visits to the ICU. PATIENT AND PUBLIC CONTRIBUTION: None in the conceptualisation or design of the study.

Dispositional optimism and all-cause mortality after esophageal cancer surgery: a nationwide population-based cohort study.

PURPOSE: To examine the association between dispositional optimism and all-cause mortality after esophageal cancer surgery and whether pathological tumor stage and the COVID-19 pandemic modified this association. METHODS: This nationwide, population-based prospective cohort study included 335 patients undergoing esophageal cancer surgery in Sweden between January 1, 2013, and December 31, 2019. Dispositional optimism was measured 1 year post-surgery using Life Orientation Test-Revised (LOT-R). A higher LOT-R sum score represents higher dispositional optimism. Mortality information was obtained from the Swedish Register of the Total Population. All patients were followed up until death or until December 31, 2020, whichever occurred first. Cox regression with adjustments for confounders was used. RESULTS: The median follow-up was 20.8 months, during which 125 (37.3%) patients died. Among the included 335 patients, 219 (65.4%) patients had tumor pathologically staged Tis-II, and 300 (89.6%) patients entered the cohort before the COVID-19 pandemic. Both tumor stage and the COVID-19 pandemic were effect modifiers. For each unit increase in LOT-R sum score, the risk of all-cause mortality decreased by 11% (HR 0.89, 95% CI 0.81 to 0.98) among patients with tumor staged Tis-II before the COVID-19 pandemic. This association was non-significant in patients with tumor staged III-IV (HR 0.99, 95% CI 0.92 to 1.07) and during the COVID-19 pandemic (HR 1.08, 95% CI 0.94 to 1.25). CONCLUSION: Assessing dispositional optimism may help predict postoperative survival, especially for patients with early and intermediate esophageal cancer. Increasing dispositional optimism might be a potential intervention target to improve survival after esophageal cancer surgery.

Cognitive Behavioral Therapy and Acceptance and Commitment Therapy (CBT-ACT) vs. Standard Care After Critical Illness Due to COVID-19: Protocol for a Pilot Randomized Controlled Trial.

Background: Post-covid syndrome is an emerging condition involving a wide range of symptoms, including high rates of poor mental health. The diagnostic relevance and clinical severity of these symptoms are largely unknown, and evidence for treatment of post-covid mental health symptoms is lacking. This protocol describes a pilot randomized clinical trial, primarily aiming to assess feasibility, participant adherence and satisfaction in a novel phycho-therapeutic intervention on post-covid anxiety and depression symptoms ≥1 year after critically ill COVID-19. Whether the intervention may generate improvements in post-covid depression, anxiety, post-traumatic stress and health-related quality of life (HRQoL) will be addressed in a following larger trial. Methods: A multicenter, investigator-initiated randomized controlled trial (Clinical Trial Identifier number NCT05119608) including Intensive Care Unit (ICU)-treated COVID-19 survivors, who display symptoms of anxiety and/or depression at follow-up 12 months after hospitalization (Hospital Anxiety and Depression Scale ≥8 for depression or anxiety). Eligible individuals are referred to a psychiatrist for structured diagnostic assessment and inclusion in the trial. Participants will be randomized to either a 10-week cognitive behavioral therapy intervention with added acceptance and commitment therapy (CBT-ACT) or standard care (primary care referral). Primary study outcome measure is feasibility and patient adherence, defined as the proportion of participants who consent to randomization and remain in the study including follow-up. Secondary outcome measures include reduced symptoms in the HADS depression/anxiety subscales, post-traumatic symptoms, HRQoL and user satisfaction at 3 months after the intervention. Discussion: This protocol describes a pilot trial to assess feasibility and preliminary effects of a structured psycho-therapeutic intervention to ameliorate mental health in a population severely affected by COVID-19, where evidence for structured psycho-therapy is lacking.

Spontaneous ethics in nurses' willingness to work during a pandemic.

Background: In modern healthcare, the role of solidarity, altruism and the natural response to moral challenges in life-threatening situations is still rather unexplored. The COVID-19 pandemic provided an opportunity to obtain a deeper understanding of nurses' willingness to care for patients during crisis.Objective: To elucidate clinical expressions of ontological situational ethics through nurses' willingness to work during a pandemic.Research design, participants and context: A qualitative study with an interpretive design was applied. Twenty nurses who worked in intensive care unit at two Swedish hospitals during the first, second, and third waves of the COVID-19 pandemic were interviewed. The analysis was interpretative and applied a theoretical ethics perspective.Ethical considerations: The study was approved by the Swedish Ethical Review Authority and informed consent was obtained from all participants.Findings: From a philosophical perspective, the nurses expressed sovereign life expressions of mercy and compassion, which arose spontaneously in response to seeing vulnerable fellow humans. They referenced ''the nurse inside me'' and their choice of profession as motives to provide care. Ontological situational ethics in culture and norms were noted in the constructs of competence, responsibility, solidarity with colleagues and organization; and interest and learning were driving forces. Ethical demand was evident when nurses expressed ideas of meaningfulness in helping their fellow humans; but themes of ambiguity, exhaustion and unwillingness were also present.Conclusions: The nurses showed a high willingness to care for patients during a crisis. Responding to the ethical demand and to care for vulnerable human beings while risking their own health and lives could be interpreted as an inter-human vocation. These spontaneous altruistic actions saved the lives of many patients during the pandemic and need to be understood and supported.

The role of ventilatory support for long-term outcomes after critical infection with COVID-19: A prospective cohort study.

OBJECTIVES: The full range of long-term health consequences in intensive care unit (ICU) survivors with COVID-19 is unclear. This study aims to investigate the role of ventilatory support for long-term pulmonary impairment in critically ill patients and further to identify risk factors for prolonged radiological recovery. METHODS: A prospective observational study from a single general hospital, including all with COVID-19 admitted to ICU between March and August 2020, investigating the association between ventilatory support and the extent of residual parenchymal changes on chest computed tomography (CT) scan and measurement of lung volumes at follow-up comparing high-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) with invasive ventilation. A semi-quantitative score (CT involvement score) based on lobar involvement and a total score for all five lobes was used to estimate residual parenchymal changes. The association was calculated with logistic regression and adjusted for age, sex, smoking, and severity of illness. RESULTS: Among the 187 eligible, 86 had a chest CT scan and 76 a pulmonary function test at the follow-up with a median time of 6 months after ICU discharge. Residual lung changes were seen in 74%. The extent of pulmonary changes was similar regardless of ventilatory support, but patients with invasive ventilation had a lower total lung capacity 84% versus 92% of predicted (p < 0.001). CONCLUSIONS: The majority of ICU-treated patients with COVID-19 had residual lung changes at 6 months of follow-up regardless of ventilator support or not, but the total lung capacity was lower in those treated with invasive ventilation.

Social distancing during the COVID-19 pandemic and health-related quality of life among esophageal cancer survivors.

PURPOSE: The purpose was to investigate whether social distancing during the COVID-19 pandemic reduced health-related quality of life (HRQL) in esophageal cancer patients and if so, to identify factors related to the HRQL changes. METHODS: A prospective Swedish nationwide study of patients who undergone surgery for esophageal cancer between 2013 and 2019. Telephone interviews were conducted 5 weeks and 13 weeks after the introduction of social distancing recommendations. The participants responded to a few scales and items from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30. Regression models adjusted for potential confounders were used to examine mean score differences (MSD) with 95% confidence intervals (CI) between compliance with the recommendations and HRQL. RESULTS: In total, 134 individuals participated in the study. At 5 weeks, a reduction in role function was seen for individuals who fully (MSD -8, 95% CI: -16 to 0) and to a large extent (MSD -19, 95% CI: -26 to -12) complied with the recommendations. Less fatigue (MSD 9, 95% CI: 3-15) was also detected for this group. Being female, elderly, having comorbidities, living in a region with higher COVID-19 incidence, living in a villa, and being considered as an at-risk person were related to changes in role function. At 13 weeks, reductions in role function continued for those who fully complied with the recommendations (MSD -10, 95% CI: -19 to -1), but the risk variables were of less importance. Improvements in fatigue were no longer detected. Global quality of life, emotional function, or insomnia remained stable over time. CONCLUSIONS: This study indicates that individuals who undergone surgery for esophageal cancer and fully or to a large extent complied with the recommendations experienced reductions in role function, but not in global quality of life or emotional function, during the COVID-19 pandemic.

Long-term consequences in critically ill COVID-19 patients: A prospective cohort study.

BACKGROUND: COVID-19 can cause severe disease with need of treatment in the intensive care unit (ICU) for several weeks. Increased knowledge is needed about the long-term consequences. METHODS: This is a single-center prospective follow-up study of COVID-19 patients admitted to the ICU for respiratory organ support between March and July 2020. Patients with invasive ventilation were compared with those with high-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) regarding functional outcome and health-related qualify of life. The mean follow-up time was 5 months after ICU discharge and included clinical history, three well-validated questionnaires about health-related quality of life and psychological health, pulmonary function test, 6-minute walk test (6MWT) and work ability. Data were analyzed with multivariable general linear and logistic regression models with 95% confidence intervals. RESULTS: Among 248 ICU patients, 200 patients survived. Of these, 113 patients came for follow-up. Seventy patients (62%) had received invasive ventilation. Most patients reported impaired health-related quality of life. Approximately one-third suffered from post-traumatic stress, anxiety and depression. Twenty-six percent had reduced total lung capacity, 34% had reduced 6MWT and 50% worked fulltime. The outcomes were similar regardless of ventilatory support, but invasive ventilation was associated with more bodily pain (MSD -19, 95% CI: -32 to -5) and <80% total lung capacity (OR 4.1, 95% CI: 1.3-16.5). CONCLUSION: Among survivors of COVID-19 who required respiratory organ support, outcomes 5 months after discharge from ICU were largely similar among those requiring invasive compared to non-invasive ventilation.

Dosing of thromboprophylaxis and mortality in critically ill COVID-19 patients.

BACKGROUND: A substantial proportion of critically ill COVID-19 patients develop thromboembolic complications, but it is unclear whether higher doses of thromboprophylaxis are associated with lower mortality rates. The purpose of the study was to evaluate the association between initial dosing strategy of thromboprophylaxis in critically ill COVID-19 patients and the risk of death, thromboembolism, and bleeding. METHOD: In this retrospective study, all critically ill COVID-19 patients admitted to two intensive care units in March and April 2020 were eligible. Patients were categorized into three groups according to initial daily dose of thromboprophylaxis: low (2500-4500 IU tinzaparin or 2500-5000 IU dalteparin), medium (> 4500 IU but < 175 IU/kilogram, kg, of body weight tinzaparin or > 5000 IU but < 200 IU/kg of body weight dalteparin), and high dose (≥ 175 IU/kg of body weight tinzaparin or ≥ 200 IU/kg of body weight dalteparin). Thromboprophylaxis dosage was based on local standardized recommendations, not on degree of critical illness or risk of thrombosis. Cox proportional hazards regression was used to estimate hazard ratios with corresponding 95% confidence intervals of death within 28 days from ICU admission. Multivariable models were adjusted for sex, age, body mass index, Simplified Acute Physiology Score III, invasive respiratory support, and initial dosing strategy of thromboprophylaxis. RESULTS: A total of 152 patients were included: 67 received low-, 48 medium-, and 37 high-dose thromboprophylaxis. Baseline characteristics did not differ between groups. For patients who received high-dose prophylaxis, mortality was lower (13.5%) compared to those who received medium dose (25.0%) or low dose (38.8%), p = 0.02. The hazard ratio of death was 0.33 (95% confidence intervals 0.13-0.87) among those who received high dose, and 0.88 (95% confidence intervals 0.43-1.83) among those who received medium dose, as compared to those who received low-dose thromboprophylaxis. There were fewer thromboembolic events in the high (2.7%) vs medium (18.8%) and low-dose thromboprophylaxis (17.9%) groups, p = 0.04. CONCLUSIONS: Among critically ill COVID-19 patients with respiratory failure, high-dose thromboprophylaxis was associated with a lower risk of death and a lower cumulative incidence of thromboembolic events compared with lower doses. TRIAL REGISTRATION: Clinicaltrials.gov NCT04412304 June 2, 2020, retrospectively registered.