Coping in times of disruption and deprivation-Experiences of family members during COVID-19 patients' critical illness: A qualitative study.

AIM: To explore the experiences and needs of family members during the course of COVID-19 critical illness from onset to rehabilitation. DESIGN: An exploratory qualitative study. METHODS: Twelve family members of surviving critically ill COVID-19 patients and restricted from visiting the patients, were interviewed digitally. Reflexive thematic analysis was used. RESULTS: Three themes were generated from the data; 'Experiencing a double burden', 'Becoming an insignificant other' and 'Regaining significance'. Family members were often ill themselves, which represented an extra burden when the patient deteriorated. From admission, the family members became bystanders, deprived of most contact with the patients, as communication and information from the intensive care unit appeared unstructured and haphazard. However, when patients were discharged, great responsibility was placed on the family members.

Return to work during first year after intensive care treatment and the impact of demographic, clinical and psychosocial factors.

OBJECTIVES: To describe work participation in survivors during first year after intensive care unit discharge and examine the impact of selected demographic, clinical and psychosocial factors on return to work 12 months after discharge. RESEARCH METHODOLOGY/DESIGN: A predefined sub-study (prospective cohort study) of a randomised controlled trial. SETTING: A Norwegian single-centre university hospital. Medical and surgical adult intensive care survivors, working/on sick leave before admission, in the intensive care unit ≥24 h, were included. MAIN OUTCOME MEASURES: Return to work three, six and 12 months after discharge, and impact of age, pre-existing comorbidities, previous serious life events, coping ability, hope and social support on return to work 12 months after discharge. RESULTS: Included were 284 patients, with mean age 47 years (SD 13.9) and 47 % women. One year after discharge, 69 % were back at work. In the regression analysis, with working at 12 months (yes/no) as the dependent variable, 178 patients, completing questionnaires at three as well as 12 months, were included. Lower age (OR 0.96, 95 % CI [0.93-0.99]), lower pre-existing comorbidities (OR 0.65, 95 % CI [0.43-0.97]), previous serious life events (OR 6.53, 95 % CI [2.14-19.94]), and greater hope at three months (OR 1.09, 95 % CI [1.01-1.17]) were all independently associated with higher odds of returning to work. CONCLUSION: Following intensive care, age, pre-existing comorbidities, experience of previous serious life events and hope all have a significant impact on return to work, and are important variables to consider during intensive care treatment and rehabilitation. IMPLICATIONS FOR CLINICAL PRACTICE: Attention must be paid to patients with prior working capability to ensure return to work after intensive care treatment. Older adults with pre-existing comorbidities might benefit from early, individualised rehabilitation to regain previous working capacity. In addition, there is also a need to support patients' hope during and after critical illness.

Occurrence and characteristics of pain after ICU discharge: A longitudinal study.

BACKGROUND: Pain is a serious problem for intensive care unit (ICU) patients, but we are lacking data on pain at the hospital ward after ICU discharge. AIMS AND OBJECTIVES: To describe pain intensity, -interference with function and -location in patients up to 1 year after ICU discharge. To identify demographic and clinical variables and their association with worst pain intensity and pain interference. DESIGN: A longitudinal descriptive secondary analysis of a randomized controlled trial on nurse-led follow-up consultations on post-traumatic stress and sense of coherence after ICU discharge. METHODS: Pain intensity, -interference, and -location were measured using Brief Pain Inventory at the hospital ward and 3, 6, and 12 months after ICU discharge. For associations, data were analysed using multivariate linear mixed models for repeated measures. RESULTS: Of 523 included patients, 68% reported worst pain intensity score above 0 (no pain) at the ward. Estimated means for worst pain intensity and -interference (from 0 to 10) after ICU discharge were 5.5 [CI 4.6-6.5] and 4.5 [CI 3.7-5.3], and decreased to 3.8 [CI 2.8-4.8] (P ≤ .001) and 2.9 [CI 2.1-3.7] after 12 months (P ≤ .001). Most common pain locations were abdomen (43%), lower lumbar back (28%), and shoulder/forearm (22%). At 12 months, post-traumatic stress (PTS) symptoms ≥25 (scale 10-70), female gender, shorter ICU stay, and more traumatic ICU memories were significantly associated with higher worst pain intensity. PTS symptoms ≥25, female gender, more traumatic ICU memories, younger age, and not having an internal medical diagnosis were significantly associated with higher pain interference. CONCLUSIONS: Early after ICU discharge pain was present in 68% of patients. Thereafter, pain intensity and -interference declined, but pain intensity was still at a moderate level at 12 months. Health professionals should be aware of patients' pain and identify potentially vulnerable patients. IMPLICATION FOR PRACTICE: Longitudinal assessment of factors associated with pain early after ICU discharge and the following year is a first step that could improve follow-up focus and contribute to reduced development of chronic pain.

Effect of Nurse-Led Consultations on Post-Traumatic Stress and Sense of Coherence in Discharged ICU Patients With Clinically Relevant Post-Traumatic Stress Symptoms-A Randomized Controlled Trial.

OBJECTIVES: To investigate the effect of nurse-led consultations on reducing post-traumatic stress symptoms and increasing sense of coherence in discharged ICU patients with clinically relevant post-traumatic stress symptoms and to identify variables associated with symptoms 12 months later. DESIGN: A pragmatic nonblinded randomized controlled trial. SETTINGS: Five surgical and medical ICUs at Oslo University Hospital. PATIENTS: Adult patients treated in the ICU greater than or equal to 24 hours were screened with Post-Traumatic Stress Scale 10 intensive part B after ICU discharge. Those scoring greater than or equal to 25 were included in the study. INTERVENTION: Patients randomized to intervention group were offered three nurse-led consultations within 2 months, and patients in the control group received standard care. MEASUREMENTS AND MAIN RESULTS: Sense of Coherence Scale 13 and Post-Traumatic Stress Scale 10 intensive part B were completed after inclusion, and reevaluated after 3, 6, and 12 months. Linear mixed model for repeated measures and linear regression analyses were performed. Among 523 screened patients, 111 and 113 were randomized to intervention group and control group, respectively. Mean Post-Traumatic Stress Scale 10 intensive part B score was 37 (±10) before randomization. No differences in post-traumatic stress symptoms or sense of coherence were found between intervention group versus control group, with a mean Post-Traumatic Stress Scale 10 intensive part B score 39 (95% CI, 37-41) versus 37 (95% CI, 35-39), 32 (95% CI, 28-35) versus 32 (95% CI, 29-35), 31 (95% CI, 28-34) versus 30 (95% CI, 27-33), and 31 (95% CI, 28-34) versus 29 (95% CI, 26-33) at baseline, 3, 6, and 12 months, respectively. There was a significantly reduced Post-Traumatic Stress Scale 10 intensive part B score for both groups during the year (p = 0.001). Low sense of coherence, pain, and previous psychiatric problems were associated with increased level of post-traumatic stress symptoms at 12 months. CONCLUSIONS: Nurse-led consultations did not reveal any significant effect on post-traumatic stress symptoms or sense of coherence after ICU discharge in patients with clinically relevant symptoms.

Post-traumatic stress symptoms and sense of coherence in proximity to intensive care unit discharge.

BACKGROUND: Post-traumatic stress (PTS) symptoms following intensive care unit (ICU) treatment can lead to post-traumatic stress disorder and represent a severe health burden. In trauma patients, a strong sense of coherence (SOC) is associated with fewer PTS symptoms. However, this association has not been investigated in a general ICU sample. AIMS AND OBJECTIVES: To examine the occurrence of PTS symptoms in general ICU patients early after ICU discharge and to assess possible associations between PTS symptoms and SOC, ICU memory, pain, and demographic and clinical characteristics. DESIGN: This was a cross-sectional study. METHODS: Adult patients aged ≥18 years admitted for ≥24 hours to five ICUs between 2014 and 2016 were recruited. PTS symptoms and SOC were measured at the ward within the first week after discharge from the ICU using the Posttraumatic Stress Scale-10 and Sense of Coherence Scale-13. Multiple linear regression analysis was used to identify associations between PTS symptoms and SOC and the selected independent variables. RESULTS: A total of 523 patients were included (17.8% trauma patients; median age 57 years [range 18-94]; 53.3% male). The prevalence of clinically significant PTS symptoms was 32%. After adjustments for gender and age, lower SOC (P < 0.001), more ICU delusional memories (P < 0.001), greater pain interference (P < 0.001), not being a trauma patient (P = 0.02), and younger age (P = 0.03) were significantly associated with more PTS symptoms. CONCLUSIONS: One third of patients experienced clinically relevant PTS symptoms early after discharge from the ICU. In the present study, SOC, delusional memory, pain interference, younger age, and not being a trauma patient were factors associated with more PTS symptoms. RELEVANCE TO CLINICAL PRACTICE: Early individual follow up after ICU discharge focusing on pain relief and delusional memory may reduce PTS symptoms, with a potential of improving rehabilitation.

Post-traumatic stress symptoms in family caregivers of intensive care unit patients: A longitudinal study.

OBJECTIVES: To describe the prevalence and trajectory of family caregivers' post-traumatic stress symptoms during the first year after a patient's admission to the intensive care unit and identify associations between family caregivers' background characteristics, hope and post-traumatic stress symptoms. RESEARCH METHODOLOGY/DESIGNS: Family caregivers of intensive care unit patients (n = 211) completed questionnaires at patient admission to the intensive care unit and thereafter at 1, 3, 6, and 12 months. Mixed-model analyses were performed. SETTING: Four intensive care units in a university hospital in Norway. MAIN OUTCOME MEASURES: Impact of Event Scale-Revised and Herth Hope Index. RESULTS: On admission, 54% of family caregivers reported high post-traumatic stress symptom levels, which decreased during the first six  months after patient discharge. Lower levels of hope, being younger, having more comorbidities and being on sick leave were associated with higher post-traumatic stress symptom levels. Being the parent of the patient was associated with decreased post-traumatic stress symptom levels. CONCLUSIONS: Family caregivers of intensive care unit patients report high levels of post-traumatic stress symptoms. Higher levels of hope were associated with fewer post-traumatic stress symptoms.

Quality of life in family caregivers of patients in the intensive care unit: A longitudinal study.

BACKGROUND: Family caregivers of patients in the intensive care unit (ICU) experience impairments in the quality of life. Previous studies report that psychological quality of life improves over time, but there has been limited longitudinal research, and measurement points have differed. Factors such as age, gender, and posttraumatic stress symptoms have been found to be associated with the quality of life, but level of hope and its associations with the quality of life have not been investigated. OBJECTIVES: The objective of this study was (1) to evaluate changes in the quality of life in family caregivers during the first year after a patient's admission to the ICU and (2) to identify associations between patients' and family caregivers' background characteristics, posttraumatic stress symptoms, hope, and quality of life. METHODS: A longitudinal study design with five measurement points was used. Family caregivers completed study questionnaires at enrolment into the study and at 1, 3, 6, and 12 months after the patient's admission to the ICU. The quality of life was measured with the 12-Item Short Form Health Survey. RESULTS: Family caregivers (N = 211) reported improved psychological quality of life during the first year after the patient's admission to the ICU, but it was still lower than the psychological quality of life reported in norm-based data. Being on sick leave, consulting healthcare professionals (e.g., general practitioner), and increased level of posttraumatic stress symptoms were significantly associated with psychological quality of life, whereas hope was not. Reported physical quality of life was comparable to norm-based data. CONCLUSION: Family caregivers of patients in the ICU reported impairments in quality of life during the first year after the patient's admission to the ICU. Being on sick leave, consulting healthcare professionals, and reduced posttraumatic stress symptoms may improve mental quality of life.

Psychological distress after physical injury: a one-year follow-up study of conscious hospitalised patients.

BACKGROUND: Acute physical injury may lead to psychological distress. The relationship between peritraumatic responses, injury severity, the personality trait of optimism/pessimism and psychological distress is not fully understood. In addition, the development of post-traumatic stress symptoms may differ in subgroups. METHODS: One hundred and eighty-one patients (18-65 years) completed questionnaires 1 (baseline), 3 and 12 months after first admission for acute physical injury. All patients were conscious on arrival. Scores on the Casualty Chain Inventory (CCI) for peritraumatic responses, the Impact of Event Scale (IES), the Hospital Anxiety and Depression Scale (HADS), the Life Orientation Test-Revised (LOT-R), trauma-related variables (ISS, Abbreviated Injury Scale [AIS], Glasgow Coma Scale [GCS]), and background variables were assessed. RESULTS: Mean IES scores were 21.5 (95% CI: 19.0-24.0) at baseline and 15.8 (13.5-18.1) at 12 months (p<0.001). One subgroup (delayed onset, 12.2%) had an increase of at least 10 points in the IES score and another subgroup (chronic, 13.3%) had high and persistent post-traumatic stress symptoms during the follow-up period. At baseline, 45.3% had an IES score ≥ 20, indicating possible clinical case levels, compared with 33.1% at 12 months. Accordingly, 14% had anxiety symptoms and 10.8% had depression symptoms at a case level (HADS ≥ 8) at one-year follow-up. Mutually independent predictors of post-traumatic stress symptoms at 12 months were dissociation (OR 1.3, 95% CI: 1.1-1.6) and perception (OR 1.1, 95% CI: 1.0-1.3) measured by the CCI. Being in work before injury (OR 0.1, 95% CI: 0.02-0.4) and higher educational level (OR 0.3, 95% CI: 0.1-0.7) were associated with fewer IES symptoms. Dissociation and having a pessimistic trait predicted anxiety and depression at 12 months. Previous psychiatric problems predicted anxiety symptoms, and high educational level predicted less depression symptoms. CONCLUSION: One-third of conscious physical injured patients had post-traumatic stress symptoms at a possible clinical case level one year after the traumatic event, and one-third of these had delayed onset. Symptoms of peritraumatic dissociation and perception were mutually independent predictors of psychological distress.

Prevalence and predictors of return to work in hospitalised trauma patients during the first year after discharge: a prospective cohort study.

OBJECTIVE: The aim of the study was to investigate the proportion of patients who return to work and predictors of return to pre-injury level of work participation the first year after trauma. METHODS: A prospective single-centre study of 188 patients aged 18-65 years with different degrees of injury severity was carried out in a trauma referral centre. All patients were working or studying full or part time before the injury. The first assessments were performed a median time of 27 days after discharge. Participation in work/education was measured 3 and 12 months after the first assessment with self-report questionnaires. The Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale (IES) were independent measures of anxiety, depression and post-traumatic stress symptoms (PTS) at baseline and 3 months. The Life Orientation Test Revised (LOT-R) measured optimism and pessimism at baseline. Predictors of return to work were identified by multiple logistic regression analysis. RESULTS: After one year, 131 patients (70%) had returned to the same level of participation in work or education; 95 (50%) had returned at 3 months. Independent predictors of return to work after 3 months were low age, low Injury Severity Score (ISS) score, not needing ventilator treatment and low score for depression symptoms, adjusted for gender (Nagelkerke R square 0.38). Low ISS, absence of serious head injury, low HADS depression score and an optimistic life orientation remained significant predictors of return to work at the same level after 12 months (Nagelkerke R square 0.38). In addition, good physical function (SF-36 PF score>65) at 3 months was an independent predictor of return to work at 12 months in the 93 patients who had not returned to work at 3 months. CONCLUSION: Independent predictors of return to work at 3 months were low age, low ISS and absence of depression symptoms. At 12 months, independent predictors of return to work were low ISS, low depression score and an optimistic life orientation. To promote early return to work, trauma patients might be screened for depression symptoms and pessimism, and intervention or treatment provided for those in need.

Health related quality of life in trauma patients. Data from a one-year follow up study compared with the general population.

BACKGROUND: Trauma patients have impaired health-related quality of life (HRQOL) after trauma. The aim of the study was to assess HRQOL during the first year after trauma and hospital stay in trauma patients admitted to an intensive-care unit (ICU) for >24 hours compared with non-ICU trauma patients and the general population, and to identify predictors of HRQOL. METHODS: A prospective one-year follow-up study of 242 trauma patients received by the trauma team of a trauma referral centre in Norway was performed. HRQOL was measured using the Medical Outcomes Study Short Form 36 (SF-36) at 3 and 12 months. RESULTS: The mean age of the cohort was 42.3 years (95% CI, 40.4-44.3 years). The median Injury Severity Score (ISS) was 10, interquartile range 16. The HRQOL improved significantly from the 3 to the 12 months follow up in the trauma patients. However their scores were significantly lower for most subscales of SF-36 compared to the general population. Significant differences between ICU and non-ICU patients at 12 months were observed only for physical functioning and role physical subscales. Optimism was an independent predictor of good HRQOL at 12 months, in all dimensions (beta, 0.95-2.45). A higher depression score at baseline predicted lower HRQOL in four of eight dimensions (beta -1.1 to -1.70). In addition, better physical functioning was predicted by lower age (beta, -0.20), and having head injury (reference) as the most severe injury vs. spine or extremity injuries (beta, -9.49 and -10.85), and better mental health by higher age (beta, 0.21) and being employed or studying before the trauma (beta, 12.27). In addition to optimism good general health was predicted by lower score for post-traumatic stress (PTS) symptoms at baseline (beta, -0.27) and lower ISS score (beta -10.59). CONCLUSIONS: The HRQOL improved significantly from the 3 to the 12 months follow up in our sample. However their scores were significantly lower for most subscales of SF-36 compared to the general population. Significant differences between ICU and non-ICU patients were observed for only two subscales. Better HRQOL at 12 months was predicted mainly by optimism, low score for depression and PTS symptoms at baseline. High ISS predicted low general health exclusively.

Psychological distress after severe trauma: a prospective 1-year follow-up study of a trauma intensive care unit population.

BACKGROUND: The aim of the study was to investigate the level of psychologic distress after trauma and intensive care unit (ICU) stay, memory from the ICU, and predictors for psychologic distress at 12 months. METHODS: Prospective single center study in a trauma referral center for Eastern and Southern Norway. Participants were 150 trauma patients treated in an ICU for > 24 hours. Assessments were performed after discharge, at 3 months, and at 12 months using the Impact of Event Scale, Hospital Anxiety and Depression Scale, ICU memory tool, and Life Orientation Test-Revised. RESULTS: At baseline, the mean Impact of Event scores were 22.7 decreasing to 18.4 at 12 months (p = 0.039). At 1-year follow-up, mean anxiety scores were 5.5 (95% confidence interval [CI]: 4.6-6.4) and depression scores 3.8 (95% CI: 3.1-4.5). Factual memories from ICU (odds ratio [OR] 6.58, [95% CI: 2.01-21.52], p = 0.002), low educational level (OR 0.29, [95% CI: 0.10-0.86] p = 0.025), not having care of children (OR 0.14, [95% CI: 0.04-0.47] p = 0.002), and female gender (OR 2.95, [95% CI: 1.04-8.34] p = 0.042) predicted posttraumatic stress symptoms at 12 months. Anxiety at 12 months was predicted only by pessimism (OR 0.83, [95% CI: 0.75-0.93] p = 0.001). Depression at 12 months was predicted by being out of work before the injury (OR 3.64, [95% CI: 1.11-11.94] p = 0.033) and pessimism (OR 0.83, [95% CI: 0.73-0.93] p = 0.002). CONCLUSIONS: Many patients suffer from posttraumatic stress symptoms, anxiety, and depression after trauma and ICU stay. The strongest predictors of psychologic distress 12 months after discharge were having factual memories from the ICU stay, being pessimistic, and being out of work before the injury.

Posttraumatic stress, anxiety and depression symptoms in patients during the first year post intensive care unit discharge.

INTRODUCTION: To study the level and predictors of posttraumatic stress, anxiety and depression symptoms in medical, surgical and trauma patients during the first year post intensive care unit (ICU) discharge. METHODS: Of 255 patients included, 194 participated at 12 months. Patients completed the Impact of Event Scale (IES), Hospital Anxiety and Depression Scale (HADS), Life Orientation Test (LOT) at 4 to 6 weeks, 3 and 12 months and ICU memory tool at the first assessment (baseline). Case level for posttraumatic stress symptoms with high probability of a posttraumatic stress disorder (PTSD) was > or = 35. Case level of HADS-Anxiety or Depression was > or = 11. Memory of pain during ICU stay was measured at baseline on a five-point Likert-scale (0-low to 4-high). Patient demographics and clinical variables were controlled for in logistic regression analyses. RESULTS: Mean IES score one year after ICU treatment was 22.5 (95%CI 20.0 to 25.1) and 27% (48/180) were above case level, IES > or = 35. No significant differences in the IES mean scores across the three time points were found (P = 0.388). In a subgroup, 27/170 (16%), patients IES score increased from 11 to 32, P < 0.001. No differences in posttraumatic stress, anxiety or depression between medical, surgical and trauma patients were found. High educational level (OR 0.4, 95%CI 0.2 to 1.0), personality trait (optimism) OR 0.9, 95%CI 0.8 to 1.0), factual recall (OR 6.6, 95%CI 1.4 to 31.0) and memory of pain (OR 1.5, 95%CI 1.1 to 2.0) were independent predictors of posttraumatic stress symptoms at one year. Optimism was a strong predictor for less anxiety (OR 0.8, 0.8 to 0.9) and depression symptoms (OR 0.8, 0.8 to 0.9) after one year. CONCLUSIONS: The mean level of posttraumatic stress symptoms in patients one year following ICU treatment was high and one of four were above case level Predictors of posttraumatic stress symptoms were mainly demographics and experiences during hospital stay whereas clinical injury related variables were insignificant. Pessimism was a predictor of posttraumatic stress, anxiety and depression symptoms. A subgroup of patients developed clinically significant distress symptoms during the follow-up period.

Patients' memory and psychological distress after ICU stay compared with expectations of the relatives.

PURPOSE: To compare patients' psychological distress and memories from intensive care unit (ICU) treatment 4-6 weeks after ICU discharge with expectations of their relatives. Further, to explore the relationship between personality traits and ICU memories with psychological distress. METHODS: A cross-sectional study of 255 patients and 298 relatives. The questionnaire included: hospital anxiety and depression scale (HADS), impact of event scale (IES), life orientation test, ICU memory tool and memory of ICU; technical procedures, pain, lack of control and inability to express needs. Relatives were assessed for their expectations of the patients' memories and psychological distress. RESULTS: Twenty-five percent of the patients reported severe posttraumatic stress symptoms, IES-total >or= 35. The levels of anxiety and depression were significantly higher than in the general population, mean anxiety was 5.6 versus 4.2 (p < 0.001), and mean depression was 4.8 versus 3.5 (p < 0.001). Relatives expected more psychological distress and the relatives thought the patient was less able to express needs than the patients reported (p < 0.001). Higher age, unemployment, respirator treatment, pessimism, memory of pain, lack of control and inability to express needs were independent predictors of posttraumatic stress symptoms (p < 0.01). CONCLUSIONS: Psychological distress symptoms were frequent among ICU survivors. Relatives expected the patients to be more distressed after ICU treatment than the patients reported. The strongest predictors of posttraumatic stress symptoms from the ICU were memoris about pain, lack of control and inability to express needs. Pessimism may be a reason for psychological distress and should be addressed during follow up, as pessimistic patients may need more motivation and support.