Patient and Caregiver-Derived Health Service Improvements for Better Critical Care Recovery.

OBJECTIVES: To engage critical care end-users (survivors and caregivers) to describe their emotions and experiences across their recovery trajectory, and elicit their ideas and solutions for health service improvements to improve the ICU recovery experience. DESIGN: End-user engagement as part of a qualitative design using the Framework Analysis method. SETTING: The Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS: Patients and caregivers following critical illness and identified through the collaboratives. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-six interviews were conducted. The following themes were identified: 1) Emotions and experiences of patients-"Loss of former self; Experiences of disability and adaptation"; 2) Emotions and experiences of caregivers-"Emotional impacts, adopting new roles, and caregiver burden; Influence of gender roles; Adaptation, adjustment, recalibration"; and 3) Patient and caregiver-generated solutions to improve recovery across the arc of care-"Family-targeted education; Expectation management; Rehabilitation for patients and caregivers; Peer support groups; Reconnecting with ICU post-discharge; Access to community-based supports post-discharge; Psychological support; Education of issues of ICU survivorship for health professionals; Support across recovery trajectory." Themes were mapped to a previously published recovery framework (Timing It Right) that captures patient and caregiver experiences and their support needs across the phases of care from the event/diagnosis to adaptation post-discharge home. CONCLUSIONS: Patients and caregivers reported a range of emotions and experiences across the recovery trajectory from ICU to home. Through end-user engagement strategies many potential solutions were identified that could be implemented by health services and tested to support the delivery of higher-quality care for ICU survivors and their caregivers that extend from tertiary to primary care settings.

Modification of social determinants of health by critical illness and consequences of that modification for recovery: an international qualitative study.

OBJECTIVES: Social determinants of health (SDoH) contribute to health outcomes. We identified SDoH that were modified by critical illness, and the effect of such modifications on recovery from critical illness. DESIGN: In-depth semistructured interviews following hospital discharge. Interview transcripts were mapped against a pre-existing social policy framework: money and work; skills and education; housing, transport and neighbourhoods; and family, friends and social connections. SETTING: 14 hospital sites in the USA, UK and Australia. PARTICIPANTS: Patients and caregivers, who had been admitted to critical care from three continents. RESULTS: 86 interviews were analysed (66 patients and 20 caregivers). SDoH, both financial and non-financial in nature, could be negatively influenced by exposure to critical illness, with a direct impact on health-related outcomes at an individual level. Financial modifications included changes to employment status due to critical illness-related disability, alongside changes to income and insurance status. Negative health impacts included the inability to access essential healthcare and an increase in mental health problems. CONCLUSIONS: Critical illness appears to modify SDoH for survivors and their family members, potentially impacting recovery and health. Our findings suggest that increased attention to issues such as one's social network, economic security and access to healthcare is required following discharge from critical care.

Optimizing Critical Illness Recovery: Perspectives and Solutions From the Caregivers of ICU Survivors.

OBJECTIVES: To understand the unmet needs of caregivers of ICU survivors, how they accessed support post ICU, and the key components of beneficial ICU recovery support systems as identified from a caregiver perspective. DESIGN: International, qualitative study. SUBJECTS: We conducted 20 semistructured interviews with a diverse group of caregivers in the United States, the United Kingdom, and Australia, 11 of whom had interacted with an ICU recovery program. SETTING: Seven hospitals in the United States, United Kingdom, and Australia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Content analysis was used to explore prevalent themes related to unmet needs, as well as perceived strategies to improve ICU outcomes. Post-ICU care was perceived to be generally inadequate. Desired caregiver support fell into two main categories: practical support and emotional support. Successful care delivery initiatives included structured programs, such as post discharge telephone calls, home health programs, post-ICU clinics, and peer support groups, and standing information resources, such as written educational materials and online resources. CONCLUSIONS: This qualitative, multicenter, international study of caregivers of critical illness survivors identified consistently unmet needs, means by which caregivers accessed support post ICU, and several care mechanisms identified by caregivers as supporting optimal ICU recovery.

Transitions of Care After Critical Illness-Challenges to Recovery and Adaptive Problem Solving.

OBJECTIVES: Investigate the challenges experienced by survivors of critical illness and their caregivers across the transitions of care from intensive care to community, and the potential problem-solving strategies used to navigate these challenges. DESIGN: Qualitative design-data generation via interviews and data analysis via the framework analysis method. SETTING: Patients and caregivers from three continents, identified through the Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS: Patients and caregivers following critical illness. INTERVENTIONS: Nil. MEASUREMENTS AND MAIN RESULTS: From 86 interviews (66 patients, 20 caregivers), we identified the following major themes: 1) Challenges for patients-interacting with the health system and gaps in care; managing others' expectations of illness and recovery. 2) Challenges for caregivers-health system shortfalls and inadequate communication; lack of support for caregivers. 3) Patient and caregiver-driven problem solving across the transitions of care-personal attributes, resources, and initiative; receiving support and helping others; and acceptance. CONCLUSIONS: Survivors and caregivers experienced a range of challenges across the transitions of care. There were distinct and contrasting themes related to the caregiver experience. Survivors and caregivers used comparable problem-solving strategies to navigate the challenges encountered across the transitions of care.

Benefits of Peer Support for Intensive Care Unit Survivors: Sharing Experiences, Care Debriefing, and Altruism.

BACKGROUND: After critical illness, patients are often left with impairments in physical, social, emotional, and cognitive functioning. Peer support interventions have been implemented internationally to ameliorate these issues. OBJECTIVE: To explore what patients believed to be the key mechanisms of effectiveness of peer support programs implemented during critical care recovery. METHODS: In a secondary analysis of an international qualitative data set, 66 telephone interviews with patients were undertaken across 14 sites in Australia, the United Kingdom, and the United States to understand the effect of peer support during recovery from critical illness. Prevalent themes were documented with framework analysis. RESULTS: Most patients who had been involved in peer support programs reported benefit. Patients described 3 primary mechanisms: (1) sharing experiences, (2) care debriefing, and (3) altruism. CONCLUSION: Peer support is a relatively simple intervention that could be implemented to support patients during recovery from critical illness. However, more research is required into how these programs can be implemented in a safe and sustainable way in clinical practice.

Prediction Models for Physical, Cognitive, and Mental Health Impairments After Critical Illness: A Systematic Review and Critical Appraisal.

OBJECTIVES: Improved ability to predict impairments after critical illness could guide clinical decision-making, inform trial enrollment, and facilitate comprehensive patient recovery. A systematic review of the literature was conducted to investigate whether physical, cognitive, and mental health impairments could be predicted in adult survivors of critical illness. DATA SOURCES: A systematic search of PubMed and the Cochrane Library (Prospective Register of Systematic Reviews ID: CRD42018117255) was undertaken on December 8, 2018, and the final searches updated on January 20, 2019. STUDY SELECTION: Four independent reviewers assessed titles and abstracts against study eligibility criteria. Studies were eligible if a prediction model was developed, validated, or updated for impairments after critical illness in adult patients. Discrepancies were resolved by consensus or an independent adjudicator. DATA EXTRACTION: Data on study characteristics, timing of outcome measurement, candidate predictors, and analytic strategies used were extracted. Risk of bias was assessed using the Prediction model Risk Of Bias Assessment Tool. DATA SYNTHESIS: Of 8,549 screened studies, three studies met inclusion. All three studies focused on the development of a prediction model to predict (1) a mental health composite outcome at 3 months post discharge, (2) return-to-pre-ICU functioning and residence at 6 months post discharge, and (3) physical function 2 months post discharge. Only one model had been externally validated. All studies had a high risk of bias, primarily due to the sample size, and statistical methods used to develop and select the predictors for the prediction published model. CONCLUSIONS: We only found three studies that developed a prediction model of any post-ICU impairment. There are several opportunities for improvement for future prediction model development, including the use of standardized outcomes and time horizons, and improved study design and statistical methodology.

Society of Critical Care Medicine's International Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness.

BACKGROUND: After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when remain unclear. OBJECTIVES: Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for postdischarge impairments. PARTICIPANTS: Thirty-one international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine's Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers. DESIGN: Society of Critical Care Medicine consensus conference on post-intensive care syndrome prediction and assessment, held in Dallas, in May 2019. A systematic search of PubMed and the Cochrane Library was conducted in 2018 and updated in 2019 to complete an original systematic review and to identify pre-existing systematic reviews. MEETING OUTCOMES: We concluded that existing tools are insufficient to reliably predict post-intensive care syndrome. We identified factors before (e.g., frailty, preexisting functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2-4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment test; Hospital Anxiety and Depression Scale; Impact of Event Scale-Revised (post-traumatic stress disorder); 6-minute walk; and/or the EuroQol-5D-5L, a health-related quality of life measure (physical function). CONCLUSIONS: Beginning with an assessment of a patient's pre-ICU functional abilities at ICU admission, clinicians have a care coordination strategy to identify and manage impairments across the continuum. As hospital discharge approaches, clinicians should use brief, standardized assessments and compare these results to patient's pre-ICU functional abilities ("functional reconciliation"). We recommend serial assessments for post-intensive care syndrome-related problems continue within 2-4 weeks of hospital discharge, be prioritized among high-risk patients, using the identified screening tools to prompt referrals for services and/or more detailed assessments.

Key Components of ICU Recovery Programs: What Did Patients Report Provided Benefit?

To understand from the perspective of patients who did, and did not attend ICU recovery programs, what were the most important components of successful programs and how should they be organized. DESIGN: International, qualitative study. SETTING: Fourteen hospitals in the United States, United Kingdom, and Australia. PATIENTS: We conducted 66 semi-structured interviews with a diverse group of patients, 52 of whom had used an ICU recovery program and 14 whom had not. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using content analysis, prevalent themes were documented to understand what improved their outcomes. Contrasting quotes from patients who had not received certain aspects of care were used to identify perceived differential effectiveness. Successful ICU recovery programs had five key components: 1) Continuity of care; 2) Improving symptom status; 3) Normalization and expectation management; 4) Internal and external validation of progress; and 5) Reducing feelings of guilt and helplessness. The delivery of care which achieved these goals was facilitated by early involvement (even before hospital discharge), direct involvement of ICU staff, and a focus on integration across traditional disease, symptom, and social welfare needs. CONCLUSIONS: In this multicenter study, conducted across three continents, patients identified specific and reproducible modes of benefit derived from ICU recovery programs, which could be the target of future intervention refinement.

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.

Would disfluency by any other name still be disfluent? Examining the disfluency effect with cursive handwriting.

When exposed to words presented under perceptually disfluent conditions (e.g., words written in Haettenschweiler font), participants have difficulty initially recognizing the words. Those same words, though, may be better remembered later than words presented in standard type font. This counterintuitive finding is referred to as the disfluency effect. Evidence for this disfluency effect, however, has been mixed, suggesting possible moderating factors. Using a recognition memory task, level of disfluency was examined as a moderating factor across three experiments using a novel cursive manipulation that varied on degree of legibility (easy-to-read cursive vs. hard-to-read cursive). In addition, list type and retention interval between study and test were manipulated. Across all three experiments, cursive words engendered better memory than type-print words. This memory effect persisted across varied list designs (blocked vs. mixed) and a longer (24-hour) retention interval. A small-scale meta-analysis across the three experiments suggested that the cursive disfluency effect is moderated by level of disfluency: easy-to-read cursive words tended to be better remembered than hard-to-read cursive words. Taken together, these results challenge extant accounts of the disfluency effect. The theoretical and practical implications of these findings are discussed.

Predictors of Second Medical Emergency Team Activation Within 24 Hours of Index Event.

This study explored the trajectory of patients who remained on a general unit after medical emergency team activation. Of those who had a second activation within 24 hours, 80% occurred within 12 hours of the baseline activation. Chest pain and recent intensive care unit discharge were associated with having a second activation. There were statistically, not clinically, significant associations between mean vital signs and second activations; however, the patterns of change may be clinically useful.

Eyes wide open: Pupil size as a proxy for inhibition in the masked-priming paradigm.

A core assumption underlying competitive-network models of word recognition is that in order for a word to be recognized, the representations of competing orthographically similar words must be inhibited. This inhibitory mechanism is revealed in the masked-priming lexical-decision task (LDT) when responses to orthographically similar word prime-target pairs are slower than orthographically different word prime-target pairs (i.e., inhibitory priming). In English, however, behavioral evidence for inhibitory priming has been mixed. In the present study, we utilized a physiological correlate of cognitive effort never before used in the masked-priming LDT, pupil size, to replicate and extend behavioral demonstrations of inhibitory effects (i.e., Nakayama, Sears, & Lupker, Journal of Experimental Psychology: Human Perception and Performance, 34, 1236-1260, 2008, Exp. 1). Previous research had suggested that pupil size is a reliable indicator of cognitive load, making it a promising index of lexical inhibition. Our pupillometric data replicated and extended previous behavioral findings, in that inhibition was obtained for orthographically similar word prime-target pairs. However, our response time data provided only a partial replication of Nakayama et al. Journal of Experimental Psychology: Human Perception and Performance, 34, 1236-1260, 2008. These results provide converging lines of evidence that inhibition operates in word recognition and that pupillometry is a useful addition to word recognition researchers' toolbox.

Comparison of circuit patency and exchange rates between 2 different continuous renal replacement therapy machines.

BACKGROUND: Continuous renal replacement therapy (CRRT) is an important tool in the care of critically ill patients. However, the impact of a specific CRRT machine type on the successful delivery of CRRT is unclear. The purpose of this study was to evaluate the effectiveness of CRRT delivery with an intensive care unit (ICU) bedside nurse delivery model for CRRT while comparing circuit patency and circuit exchange rates in 2 Food and Drug Administration-approved CRRT devices. This article presents the data comparing circuit exchange rates for 2 different CRRT machines. MATERIALS AND METHODS: A group of ICU nurses were selected to undergo expanded training in CRRT operation and empowered to deliver all aspects of CRRT. The ICU nurses then provided all aspects of CRRT on 2 Food and Drug Administration-approved CRRT devices for 6 months. Each device was used exclusively in the designated ICU for a 2-week run-in period followed by 3-month data collection period. The primary end point for the study was the differences in average number of filter exchanges per day during each CRRT event. RESULTS: A total of 45 unique patients who underwent 64 separate CRRT treatment periods were included. Four CRRT events were excluded (see text for details). Twenty-eight CRRT events occurred in the NxStage System One arm (NxStage Medical, Lawrence, Mass) and 32 events in the Gambro Prismaflex arm (Gambro Renal Products, Boulder, Colo). Average (SD) filter exchanges per day was 0.443 (0.60) for the NxStage System One machine and 0.553 (0.65) for Gambro Prismaflex machine (P = .09). CONCLUSIONS: There was no demonstrable difference in circuit patency as defined by the rate of filter exchanges per day of CRRT therapy.

The turn team: a novel strategy for reducing pressure ulcers in the surgical intensive care unit.

BACKGROUND: Pressure ulcers cause significant morbidity and mortality in the surgical intensive care unit (SICU). The purpose of this study was to determine if a dedicated team tasked with turning and repositioning all hemodynamically stable SICU patients could decrease the formation of pressure ulcers. STUDY DESIGN: A total of 507 patients in a 20-bed SICU in a university hospital were assessed for pressure ulcers using a point prevalence strategy, between December 2008 and September 2010, before and after implementation of a team tasked with turning and repositioning all hemodynamically stable patients every 2 hours around the clock. RESULTS: At baseline, when frequent turning was encouraged but not required, a total of 42 pressure ulcers were identified in 278 patients. After implementation of the turn team, a total of 12 pressure ulcers were identified in 229 patients (p < 0.0001). The preintervention group included 34 stage I and II ulcers and 8 higher stage ulcers. After implementation of the turn team, there were 7 stage I and II ulcers and 5 higher stage ulcers. The average Braden score was 16.5 in the preintervention group and 13.4 in the postintervention group (p = 0.04), suggesting that pressure ulcers were occurring in higher risk patients after implementation of the turn team. CONCLUSIONS: A team dedicated to turning SICU patients every 2 hours dramatically decreased the incidence of pressure ulcers. The majority of stage I and stage II ulcers appear to be preventable with an aggressive intervention aimed at pressure ulcer prevention.

Orthographic similarity: the case of "reversed anagrams".

How orthographically similar are words such as paws and swap, flow and wolf, or live and evil? According to the letter position coding schemes used in models of visual word recognition, these reversed anagrams are considered to be less similar than words that share letters in the same absolute or relative positions (such as home and hose or plan and lane). Therefore, reversed anagrams should not produce the standard orthographic similarity effects found using substitution neighbors (e.g., home, hose). Simulations using the spatial coding model (Davis, Psychological Review 117, 713-758, 2010), for example, predict an inhibitory masked-priming effect for substitution neighbor word pairs but a null effect for reversed anagrams. Nevertheless, we obtained significant inhibitory priming using both stimulus types (Experiment 1). We also demonstrated that robust repetition blindness can be obtained for reversed anagrams (Experiment 2). Reversed anagrams therefore provide a new test for models of visual word recognition and orthographic similarity.

Repetition blindness: an emergent property of inter-item competition.

Repeating an item in a brief or rapid display usually produces faster or more accurate identification of the item (repetition priming), but sometimes produces the opposite effect (repetition blindness). We present a theory of short-term repetition effects, the competition hypothesis, which explains these paradoxical outcomes. The central tenet of the theory is that repetition produces a representation with a higher signal-to-noise ratio but also produces a disadvantage in the representation's ability to compete with other items for access to awareness. A computational implementation of the competition hypothesis was developed to simulate standard findings in the RB literature and to generate novel predictions which were then tested in three experiments. Results from these experiments suggest that repetition effects emerge from competitive interactions between items and that these influences extend to adjacent, nonrepeated items in the display. The results also present challenges to existing theories of short-term repetition effects.

The role of autonomic arousal in feelings of familiarity.

Subjective feelings of familiarity associated with a stimulus tend to be strongest when specific information about the previous encounter with the stimulus is difficult to retrieve (e.g., the butcher-on-the-bus phenomenon; [Mandler, G. (1980). Recognizing: The judgment of previous occurrence. Psychological Review, 87, 252-271.]). When a stimulus has been encountered previously and the circumstances of the encounter cannot be recollected, additional cognitive resources may be directed toward recollection processes; this resource allocation is accompanied by autonomic arousal [Dawson, M. E., Filion, D. L., & Schell, A. M. (1989). Is elicitation of the autonomic orienting response associated with allocation of processing resources?. Psychophysiology, 26, 560-572]. One easily measurable index of autonomic arousal is the skin conductance response (SCR). In the present study, participants studied lists of words and then gave recognition ratings to briefly displayed and masked studied and nonstudied test words while their SCRs were monitored. Results revealed a relationship between recognition ratings and the temporal characteristics of the SCR, supporting the idea that feelings of familiarity are indeed "feelings" in that they stem from autonomic arousal associated with cognitive resource allocation.

Now you see it, now you don't: repetition blindness for nonwords.

Repetition blindness (RB) for nonwords has been found in some studies, but not in others. The authors propose that the discrepancy in results is fueled by participant strategy; specifically, when rapid serial visual presentation lists are short and participants are explicitly informed that some trials will contain repetitions, participants are able to use partial orthographic information to correctly guess repetitions on repetition trials while avoiding spurious repetition reports on control trials. The authors first replicated V. Coltheart and R. Langdon's (2003) finding of RB for words but repetition advantage for nonwords (Experiment 1). When all participants were encouraged to utilize partial information in a same/different matching task along with an identification task, a repetition advantage was observed for both words and nonwords (Experiment 2). When guessing of repetitions was made detectable by including non-identical but orthographically similar items in the experiments, the repetition advantage disappeared; instead, RB was found for both words and nonwords (Experiments 3 and 4). Finally, when experiments did not contain any identical items, participants almost never reported repetitions, and reliable RB was found for orthographically similar words and nonwords (Experiments 5 and 6).

Semantic interference and associative facilitation from words presented in rapid serial visual presentation.

Semantic interference in picture naming is readily obtained when categorically related distractor words are displayed with picture targets; however, this is not typically the case when both primes and targets are words. Researchers have argued that to obtain semantic interference for word primes and targets, the prime must be shown for a sufficient duration, prime processing must be made difficult, and participants must attend to the primes. In this article, we used a novel procedure for prime presentation to investigate semantic interference in word naming. Primes were presented as the last word of a rapid serial visual presentation stream, with the target following 600-1,200 msec later. Semantic interference was observed for categorically related targets, whereas facilitation was found for associatively related targets.