In-person peer support for critical care survivors: The ICU REcovery Solutions cO-Led through surVivor Engagement (ICURESOLVE) pilot randomised controlled trial.

BACKGROUND: Peer support is a promising intervention to mitigate post-ICU disability, however there is a paucity of rigorously designed studies. OBJECTIVES: The objective of this study was to establish feasibility of an in-person, co-designed, peer-support model. METHODS: Prospective, randomised, adaptive, single-centre pilot trial with blinded outcome assessment, conducted at a university-affiliated hospital in Melbourne, Australia. Intensive care unit survivors (and their nominated caregiver, where survivor and caregiver are referred to as a dyad), >18 years of age, able to speak and understand English and participate in phone surveys, were eligible. Participants were randomised to the peer-support model (six sessions, fortnightly) or usual care (no follow-up or targeted information). Two sequential models were piloted: 1. Early (2-3 weeks post hospital discharge) 2. Later (4-6 weeks post hospital discharge). Primary outcome was feasibility of implementation measured by recruitment, intervention attendance, and outcome completion. Secondary outcomes included post-traumatic stress and social support. RESULTS: Of the 231 eligible patients, 80 participants were recruited. In the early model we recruited 38 participants (28 patients, 10 carers; 18 singles, 10 dyads), with an average (standard deviation) age of 60 (18) years; 55 % were female. Twenty-two participants (58 %) were randomised to intervention. Participants in the early intervention model attended a median (interquartile range) of 0 (0-1) sessions (total 24 sessions), with 53% (n = 20) completing the main secondary outcome of interest (Impact of Event Scale) at the baseline and 37 % (n = 14) at the follow-up. For the later model we recruited 42 participants (32 patients, 10 carers; 22 singles, 10 dyads), with an average (standard deviation) age of 60.4 (15.4) years; 50 % were female. Twenty-one participants (50 %) were randomised to intervention. The later intervention model attended a median (interquartile range) of 1 (0-5) sessions (total: 44 sessions), with the main secondary outcome impact of events scale (IES-R) completed by 41 (98 %) participants at baseline and 29 (69 %) at follow-up. CONCLUSIONS: In this pilot trial, a peer-support model that required in-person attendance delivered in a later posthospital phase of recovery appeared more feasible than an early model. Further research should investigate alternative modes of intervention delivery to improve feasibility (ACTRN12621000737831).

Activin A level is associated with physical function in critically ill patients.

BACKGROUND: Activin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels. OBJECTIVES: The objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital. METHODS: Thirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for >48 h and expected to have a total ICU stay of >5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU. RESULTS: High peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: -91.3, -154.2 to -28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures. CONCLUSIONS: Higher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness. STUDY REGISTRATION: ACTRN12615000047594.

Key mechanisms by which post-ICU activities can improve in-ICU care: results of the international THRIVE collaboratives.

OBJECTIVE: To identify the key mechanisms that clinicians perceive improve care in the intensive care unit (ICU), as a result of their involvement in post-ICU programs. METHODS: Qualitative inquiry via focus groups and interviews with members of the Society of Critical Care Medicine's THRIVE collaborative sites (follow-up clinics and peer support). Framework analysis was used to synthesize and interpret the data. RESULTS: Five key mechanisms were identified as drivers of improvement back into the ICU: (1) identifying otherwise unseen targets for ICU quality improvement or education programs-new ideas for quality improvement were generated and greater attention paid to detail in clinical care. (2) Creating a new role for survivors in the ICU-former patients and family members adopted an advocacy or peer volunteer role. (3) Inviting critical care providers to the post-ICU program to educate, sensitize, and motivate them-clinician peers and trainees were invited to attend as a helpful learning strategy to gain insights into post-ICU care requirements. (4) Changing clinician's own understanding of patient experience-there appeared to be a direct individual benefit from working in post-ICU programs. (5) Improving morale and meaningfulness of ICU work-this was achieved by closing the feedback loop to ICU clinicians regarding patient and family outcomes. CONCLUSIONS: The follow-up of patients and families in post-ICU care settings is perceived to improve care within the ICU via five key mechanisms. Further research is required in this novel area.

Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness: The Thrive Collaboratives.

OBJECTIVES: Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them. DESIGN: Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data. SETTING: Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents. SUBJECTS: Clinicians from 21 sites. MEASUREMENT AND MAIN RESULTS: Ten enablers and nine barriers to implementation of "ICU follow-up clinics" were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of "peer support groups" were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising. CONCLUSIONS: Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.

Evaluation of the implementation of a Tracheostomy Review Services (TRS): an observational cohort study.

It has been suggested that interprofessional tracheostomy teams improve safety, enhance outcomes and promote excellence. This study evaluated the effect of a Tracheostomy Review Service (TRS) on patient outcomes and staff attitudes. The TRS reviewed patients with a tracheostomy tube (TT) in situ on our wards. Data was collected via medical record audit. Two years of retrospective data (n = 39) was compared with 12 months of prospective data (n = 28) for: length of cannulation (LOC); length of ward-based cannulation (LOWBC); length of stay (LOS); ICU LOS (ICU-length of stay); the frequency and time to trial one way valve (PMV); and tracheostomy-related adverse events (AE). Staff were also surveyed regarding their knowledge and confidence in tracheostomy management. No significant difference was seen in LOC, LOWBC, LOS, ICU-LOS, and AE. A significant increase was seen in the frequency of PMV use (pre-TRS 74%; post-TRS 100%). Staff reported an improvement in knowledge and confidence in more complex areas of tracheostomy management. Limited measureable improvements in patient outcomes were seen following the implementation of a TRS. Limitations of this study include a small sample size and heterogeneous patient characteristics.

Development of a Peer Support Model Using Experience-Based Co-Design to Improve Critical Care Recovery.

To use experience-based co-design to identify the key design requirements of a peer support model for critical care survivors; understand the use of the experience-based co-design method from clinician, patients, and family perspectives. DESIGN: Using experience-based co-design, qualitative data about participants' preferences for a peer support model were generated via workshops. Participants' perspectives of experience-based co-design were evaluated with focus groups. SETTING: University-affiliated hospital in Melbourne, Australia. SUBJECTS: Snowball sampling was used to recruit clinicians from across the care spectrum (ICU-community); critical care survivors and nominated family members were recruited using convenience sampling. MEASUREMENTS AND MAIN RESULTS: Consensus on a peer support model was reached through the experience-based co-design process, with the following key themes: 1) socialization and group cohesion; 2) management of potential risks; and 3) individualized needs of patients and families. Evaluation of participants' perspectives of the experience-based co-design method identified five key themes: 1) participation as a positive experience; 2) emotional engagement in the process; 3) learning from patients and family members; 4) feeling heard; and 5) practical challenges of experience-based co-design and readiness to participate. CONCLUSIONS: Experience-based co-design was a feasible approach to developing a peer support model for use with critical care survivors and was well received by participants. Future testing of the co-designed peer support model in a pilot randomized controlled trial will enhance understanding of peer support in critical care and the use of experience-based co-design as a design methodology.

Models of Peer Support to Remediate Post-Intensive Care Syndrome: A Report Developed by the Society of Critical Care Medicine Thrive International Peer Support Collaborative.

OBJECTIVES: Patients and caregivers can experience a range of physical, psychologic, and cognitive problems following critical care discharge. The use of peer support has been proposed as an innovative support mechanism. DESIGN: We sought to identify technical, safety, and procedural aspects of existing operational models of peer support, among the Society of Critical Care Medicine Thrive Peer Support Collaborative. We also sought to categorize key distinctions between these models and elucidate barriers and facilitators to implementation. SUBJECTS AND SETTING: Seventeen Thrive sites from the United States, United Kingdom, and Australia were represented by a range of healthcare professionals. MEASUREMENTS AND MAIN RESULTS: Via an iterative process of in-person and email/conference calls, members of the Collaborative defined the key areas on which peer support models could be defined and compared, collected detailed self-reports from all sites, reviewed the information, and identified clusters of models. Barriers and challenges to implementation of peer support models were also documented. Within the Thrive Collaborative, six general models of peer support were identified: community based, psychologist-led outpatient, models-based within ICU follow-up clinics, online, groups based within ICU, and peer mentor models. The most common barriers to implementation were recruitment to groups, personnel input and training, sustainability and funding, risk management, and measuring success. CONCLUSIONS: A number of different models of peer support are currently being developed to help patients and families recover and grow in the postcritical care setting.

Understanding drinking among midlife men in the United Kingdom: A systematic review of qualitative studies.

OBJECTIVES: This study reviews qualitative research into the sociocultural meanings and subjective experiences that midlife men in the United Kingdom (UK) associate with their drinking. In the UK, average weekly alcohol consumption is highest among midlife men, and they are disproportionately affected by alcohol harm. There is increasing recognition that public health messages to support behaviour change must be based on an in-depth understanding of drinking motivations and experiences. STUDY DESIGN AND METHODS: Systematic literature review of studies exploring motivations for and experiences of drinking among UK men aged 45-60 using qualitative methodology. Medline, PsycINFO and the Social Science Citation Index were used, along with manual searches of key journals, Google searches and a call for evidence. The Critical Appraisal Skills Programme tool was used to quality-assess papers. Thematic synthesis was used to combine and analyse the data. RESULTS: From 5172 titles and abstracts (1995-2018), 11 publications were included, representing 6 unique studies. Five themes were identified: 'Drinking Motivations'; 'Drinking Justifications'; 'Drinking Strategies and Control'; 'Social Norms and Identity' and 'Harm'. Motivations for drinking among midlife men were associated with relaxation, socialising and maintenance of male friendships. They justified drinking as a choice and emphasised their ability to meet responsibilities, which they contrasted with 'problem drinkers'. Social norms governed drinking behaviours as an expression of masculinity. CONCLUSION: This review highlights the significance of the meanings and social importance of alcohol consumption among midlife men. Interventions using information and guidance should consider these when aiming to effectively influence the way this group drinks.

Lifecourse transitions, gender and drinking in later life.

Older people consume less alcohol than any other adult age group. However, in recent years survey data on alcohol consumption in the United Kingdom have shown that while younger age groups have experienced a decline in alcohol consumption, drinking behaviours among the elderly have not reduced in the same way. This paper uses data from the English Longitudinal Study of Ageing to analyse both the frequency and quantity of older adult's alcohol consumption using a lifecourse approach over a ten-year period. Overall drinking declined over time and the analysis examined how socio-economic characteristics, partnership, employment and health statuses were associated with differences in drinking behaviours and how these changed over time. Higher wealth and level of education were associated with drinking more and drinking more frequently for men and women. Poorer self-rated health was associated with less frequent consumption and older people with poor and deteriorating health reported a steeper decline in the frequency of alcohol consumption over time. Men who were not in a partnership drank more than other men. For women, loss of a partner was associated with a steeper decline in drinking behaviours. These findings have implications for programmes to promote responsible drinking among older adults as they suggest that, for the most part, characteristics associated with sustaining wellbeing in later life are also linked to consuming more alcohol.

Using simulation pedagogy to teach clinical education skills: A randomized trial.

INTRODUCTION: Supervision of students is a key role of senior physiotherapy clinicians in teaching hospitals. The objective of this study was to test the effect of simulated learning environments (SLE) on educators' self-efficacy in student supervision skills. METHODS: A pilot prospective randomized controlled trial with concealed allocation was conducted. Clinical educators were randomized to intervention (SLE) or control groups. SLE participants completed two 3-hour workshops, which included simulated clinical teaching scenarios, and facilitated debrief. Standard Education (StEd) participants completed two online learning modules. Change in educator clinical supervision self-efficacy (SE) and student perceptions of supervisor skill were calculated. Between-group comparisons of SE change scores were analyzed with independent t-tests to account for potential baseline differences in education experience. RESULTS: Eighteen educators (n = 18) were recruited (SLE [n = 10], StEd [n = 8]). Significant improvements in SE change scores were seen in SLE participants compared to control participants in three domains of self-efficacy: (1) talking to students about supervision and learning styles (p = 0.01); (2) adapting teaching styles for students' individual needs (p = 0.02); and (3) identifying strategies for future practice while supervising students (p = 0.02). CONCLUSIONS: This is the first study investigating SLE for teaching skills of clinical education. SLE improved educators' self-efficacy in three domains of clinical education. Sample size limited the interpretation of student ratings of educator supervision skills. Future studies using SLE would benefit from future large multicenter trials evaluating its effect on educators' teaching skills, student learning outcomes, and subsequent effects on patient care and health outcomes.

Is regular drinking in later life an indicator of good health? Evidence from the English Longitudinal Study of Ageing.

BACKGROUND: Older people who drink have been shown to have better health than those who do not. This might suggest that moderate drinking is beneficial for health, or, as considered here, that older people modify their drinking as their health deteriorates. The relationship between how often older adults drink and their health is considered for two heath states: self-rated health (SRH) and depressive symptoms. METHODS: Data were analysed from the English Longitudinal Study of Ageing (ELSA), a prospective cohort study of older adults, using multilevel ordered logit analysis. The analysis involved 4741 participants present at wave 0, (1998/1999 and 2001), wave 4 (2008/2009) and wave 5 (2010/2011). The outcome measure was frequency of drinking in last year recorded at all three time points. RESULTS: Older adults with fair/poor SRH at the onset of the study drank less frequently compared with adults with good SRH (p<0.05). Drinking frequency declined over time for all health statuses, though respondents with both continual fair/poor SRH and declining SRH experienced a sharper reduction in the frequency of their drinking over time compared with older adults who remained in good SRH or whose health improved. The findings were similar for depression, though the association between depressive symptoms and drinking frequency at the baseline was not significant after adjusting for confounding variables. CONCLUSIONS: The frequency of older adults' drinking responds to changes in health status and drinking frequency in later life may be an indicator, rather than a cause, of health status.

Mobilization of ventilated patients in the intensive care unit: An elicitation study using the theory of planned behavior.

PURPOSE: Early mobilization in intensive care unit (ICU) is safe, feasible, and beneficial. However, mobilization frequently does not occur in practice. The study objective was to elicit attitudinal, normative, and control beliefs (barriers and enablers) toward the mobilization of ventilated patients, to inform development of targeted implementation interventions. MATERIALS AND METHODS: A 9-item elicitation questionnaire was administered electronically to a convenience sample of multidisciplinary staff in a tertiary ICU. A snowball recruitment approach was used to target a sample size of 20 to 25. Two investigators performed word count and thematic analyses independently. Themes were cross-checked by a third investigator. RESULTS: Twenty-two questionnaires were completed. Respondents wrote the most text about disadvantages. Positive attitudinal beliefs included better respiratory function, reduced functional decline, and reduced muscle wasting/weakness. The main negative attitudinal beliefs were that mobilization is perceived as time consuming and poses a risk of line dislodgement/disconnection. Positive control beliefs (enablers) included increased staff availability, positive staff attitudes, engagement, and teamwork. Negative control beliefs (barriers) included unstable patient physiology and negative workplace culture. CONCLUSIONS: Intensive care unit staff expressed positive and negative attitudinal, normative, and control beliefs across the spectrum, and disadvantages were most frequently reported. Identified beliefs can be used to inform development of future interventions.

Is alcohol consumption in older adults associated with poor self-rated health? Cross-sectional and longitudinal analyses from the English Longitudinal Study of Ageing.

BACKGROUND: Increases in alcohol related mortality and morbidity have been reported among older people in England over the last decade. There is, however, evidence that drinking is protective for some health conditions. The validity of this evidence has been questioned due to residual confounding and selection bias. The aim of this study is to clarify which drinking profiles and other demographic characteristics are associated with poor self-rated health among a community-based sample of older adults in England. The study also examines whether drinking designated as being "increasing-risk" or "higher-risk" is associated with poorer self-rated health. METHOD: This study used data from Wave 0, Wave 1 and Wave 5 of the English Longitudinal Study of Ageing [ELSA]. Logistic regression analysis, was used to examine the association between drinking profiles (based on quantity and frequency of drinking) and self-rated health, adjusting for gender, age, wealth, social class, education, household composition, smoking and body mass index [BMI]. RESULTS: Twenty percent of the sample reported drinking above the recommended level at wave 0. Rates of poor self-rated health were highest among those who had stopped drinking, followed by those who never drank. The rates of poor self-rated health among non-drinkers were significantly higher than the rates of poor self-rated health for any of the groups who reported alcohol consumption. In the adjusted logistic regression models there were no drinking profiles associated with significantly higher rates of poor self-rated health relative to occasional drinkers. CONCLUSIONS: Among those who drank alcohol, there was no evidence that any pattern of current alcohol consumption was associated with poor self-rated health, even after adjustment for a wide range of variables. The results associated with the stopped drinking profile indicate improvement in self-rated health can be associated with changes in drinking behaviour. Although several limitations of the study are noted, policy makers may wish to consider how these findings should be translated into drinking guidelines for older adults.

Future of specialised roles in allied health practice: who is responsible?

Allied health professions have developed specialised advanced and extended scope roles over the past decade, for the benefit of patient outcomes, allied health professionals' satisfaction and to meet labour and workforce demands. There is an essential need for formalised, widely recognised training to support these roles, and significant challenges to the delivery of such training exist. Many of these roles function in the absence of specifically defined standards of clinical practice and it is unclear where the responsibility for training provision lies. In a case example ofphysiotherapy practice in the intensive care unit, clinical placements and independence of practice are not core components of undergraduate physiotherapy degrees. Universities face barriers to the delivery of postgraduate specialised training and, although hospital physiotherapy departments are ideally placed, resources for training are lacking and education is not traditionally considered part of healthcare service providers' core business. Substantial variability in training, and its evaluation, leads to variability in practice and may affect patient outcomes. Allied health professionals working in specialised roles should develop specific clinical standards ofpractice, restructure models ofhealth care delivery to facilitate training, continue to develop the evidence base for their roles and target and evaluate training efficacy to achieve independent practice in a cost-effective manner. Healthcare providers must work with universities, the vocational training sector and government to optimise the ability of allied health to influence decision making and care outcomes for patients.

'They don't live in my house every day': How understanding lives can aid understandings of smoking.

While the prevalence of smoking in western countries has substantially reduced following the introduction of comprehensive tobacco control programs, reduction strategies such as the introduction of smokefree legislation, media campaigns and individual and group support for people trying to quit have been less successful with people living on low income, suggesting the need for new ways to engage with people who smoke. We argue that, rather than focusing solely on researching smoking behaviors to generate new understandings of why people smoke, people working in the broad area of public health should look more widely at peoples' lives in order to understand their smoking. Using a biographical, narrative perspective as part of a wider ethnographic study of 12 families living in one community within Liverpool in 2006, we argue that understandings that position smoking purely as a harmful, deviant behavior, fail to capture the cultural complexity of the lives of smokers and the changing place and meaning of cigarettes over a person's lifetime, and may explain why smokers fail to engage with smoking cessation services and continue to smoke.

Parental smoking and children's anxieties: An appropriate strategy for health education?

While the prevalence of smoking has declined in the UK in recent years, class differentials in smoking behaviour have become more marked and smoking is increasingly recognised as a causal factor in inequalities in health. Health education initiatives to support both smoking cessation and to teach children about the health risks of smoking remain key initiatives in reducing health inequalities. However, teaching children about the risks of smoking and the impact of parental smoking in their health is not straightforward for children from backgrounds who are more likely to encounter smoking at home and in their local communities. These children have to reconcile the key messages taught at school and reinforced in smoking cessation campaigns with the knowledge that their parents and other family members smoke. In this paper we consider how children from smoking homes make sense of these education and health campaigns as observed by their parents, and the impact that this has on both parental smoking and relationships within the home. The paper thus seeks to challenge assumptions about the delivery of health education and the need to acknowledge family diversity.

'I've never ever let anyone hold the kids while they've got ciggies': moral tales of maternal smoking practices.

Smoking in the home is, potentially, the next frontier in tobacco control in the developed world. As smoking regulations in public space are extended, attention is turning to private spaces and the contribution of parental, particularly maternal, smoking to children's health and socio-economic inequalities in family health. Yet relatively little is known about mothers' smoking practices within the home and the social meanings of smoking that are constructed by these practices. In this paper we explore how mothers who smoke construct moralities of their smoking behaviour, particularly in relation to where and with whom they smoke. Drawing on in-depth Biographic Narrative Interpretative Method, in interviews with 12 smoking mothers, and their partners, we consider how these moral tales involve comparisons with other smokers and the importance of community endorsement of smoking practices, particularly around children. We also consider the role of children in the home and how children are actively involved in the regulation of smoking behaviours. Finally, we consider the implications of these moral tales for interventions around smoke-free homes.