Barriers and facilitators to resuming meaningful daily activities among critical illness survivors in the UK: a qualitative content analysis.

OBJECTIVE: To identify critical illness survivors' perceived barriers and facilitators to resuming performance of meaningful activities when transitioning from hospital to home. DESIGN: Secondary content analysis of semistructured interviews about patients' experiences of intensive care (primary analysis disseminated on the patient-facing website www.healthtalk.org). Two coders characterised patient-perceived barriers and facilitators to resuming meaningful activities. To facilitate clinical application, we mapped the codes onto the Person-Task-Environment model of performance, a patient-centred rehabilitation model that characterises complex interactions among the person, task and environment when performing activities. SETTING: United Kingdom, 2005-2006. PARTICIPANTS: 39 adult critical illness survivors, sampled for variation among demographics and illness experiences. RESULTS: Person-related barriers included negative mood or affect, perceived setbacks; weakness or limited endurance; pain or discomfort; inadequate nutrition or hydration; poor concentration/confusion; disordered sleep/hallucinations/nightmares; mistrust of people or information; and altered appearance. Task-related barriers included miscommunication and managing conflicting priorities. Environment-related barriers included non-supportive health services and policies; challenging social attitudes; incompatible patient-family coping (emotional trauma and physical disability); equipment problems; overstimulation; understimulation; and environmental inaccessibility. Person-related facilitators included motivation or attitude; experiencing progress; and religion or spirituality. Task-related facilitators included communication. Environment-related facilitators included support from family, friends or healthcare providers; supportive health services and policies; equipment; community resources; medications; and accessible housing. Barriers decreased and facilitators increased over time. Six barrier-facilitator domains dominated based on frequency and emphasis across all performance goals: mood/motivation, setbacks/progress, fatiguability/strength; mis/communication; lack/community support; lack/health services and policies. CONCLUSIONS: Critical illness survivors described a comprehensive inventory of 18 barriers and 11 facilitators that align with the Person-Task-Environment model of performance. Six dominant barrier-facilitator domains seem strong targets for impactful interventions. These results verify previous knowledge and offer novel opportunities for optimising patient-centred care and reducing disability after critical illness.

Exploring Occupational Therapists' Experiences in U.S. Primary Care Settings: A Qualitative Study.

IMPORTANCE: Occupational therapy's scope of practice aligns with the goals of comprehensive primary care set forth by the 2010 Patient Protection and Affordable Care Act (Pub. L. 111-148). To successfully integrate occupational therapy into primary care, we must understand occupational therapy practitioners' experiences in this setting. OBJECTIVE: To explore facilitators of, barriers to, and recommendations for integrating occupational therapy into primary care. DESIGN: A descriptive qualitative design that incorporated semistructured interviews, member checking sessions, and deductive thematic analysis. Interviews were structured to capture occupational therapists' experiences of and recommendations for practicing in primary care. SETTING: Primary care. PARTICIPANTS: A purposive sample of licensed occupational therapists with at least 6 mo primary care experience in the United States. RESULTS: Seven participants reported 1 to 8 yr of experience in primary care. Four themes emerged that contextualized the experiences of occupational therapists in primary care. The first theme captured the process of gaining entry onto the primary care team. Once structurally embedded on the team, the second and third themes, respectively, captured barriers and facilitators to navigating team-based care and providing patient-centered care. The fourth theme reflected participants' vision and ideas of how to expand reach nationally to promote consistent integration of occupational therapy into primary care. Conclusion and Relevance: Given the important role of an interprofessional primary care team in improving population health, this study is timely in that it explored occupational therapists' experiences in this emerging practice area. What This Article Adds: Occupational therapists in this study used their skills, resources, and networks to become part of a primary care team. They indicated that they contributed to positive outcomes through working with patients on self-management, functional problem solving, and behavior change.

Post-Intensive Care Unit Care. A Qualitative Analysis of Patient Priorities and Implications for Redesign.

Rationale: Although survival during critical illness is improving, little evidence exists to guide post-intensive care unit (ICU) care. Understanding patients' needs and priorities is fundamental to improving care quality.Objectives: To describe the evolution of patients' priorities for recovery across the spectrum of post-ICU care.Methods: This was a secondary analysis of 39 semistructured interviews conducted from 2005 to 2006 in participants' homes 19 days to 11 years after hospital discharge after critical illness. Adult critical illness survivors (N = 39) aged 20 years or older from multiple ICUs across the United Kingdom were purposively selected to maximize diversity with respect to time since diagnosis, disease severity, sex, age, ethnicity, socioeconomic group/status, region. age, ICU admitting diagnoses, and length of stay. We used the method of qualitative description to characterize patients' priorities for recovery and their evolution within and between individual patients across three post-ICU periods: ICU transition to wards, early period (approximately the first 2 mo) after discharge to home, and late period (>2 mo) after discharge to home.Results: The analysis revealed 12 core patient priorities during recovery: feeling safe, being comfortable, engaging in mobility, participating in self-care, asserting personhood, connecting with people, ensuring family well-being, going home, restoring psychological health, restoring physical health, resuming previous roles and routines, and seeking new life experiences. In general, priorities evolved from those pertaining to basic survival during the stay on wards to being broader and more aspirational by the late postdischarge period.Conclusions: Understanding patients' priorities for post-ICU care is critical for developing stakeholder-driven clinical guidelines. Engaging other stakeholders (e.g., family members, healthcare providers, and institutionalized and frail older adults) to inform the development of clinical guidelines for post-ICU care, together with the barriers and facilitators faced in achieving patient- and family-centered care, is an important next step.

Analysis of the chronic wound microbiota of 2,963 patients by 16S rDNA pyrosequencing.

The extent to which microorganisms impair wound healing is an ongoing controversy in the management of chronic wounds. Because the high diversity and extreme variability of the microbiota between individual chronic wounds lead to inconsistent findings in small cohort studies, evaluation of a large number of chronic wounds using identical sequencing and bioinformatics methods is necessary for clinicians to be able to select appropriate empiric therapies. In this study, we utilized 16S rDNA pyrosequencing to analyze the composition of the bacterial communities present in samples obtained from patients with chronic diabetic foot ulcers (N = 910), venous leg ulcers (N = 916), decubitus ulcers (N = 767), and nonhealing surgical wounds (N = 370). The wound samples contained a high proportion of Staphylococcus and Pseudomonas species in 63 and 25% of all wounds, respectively; however, a high prevalence of anaerobic bacteria and bacteria traditionally considered commensalistic was also observed. Our results suggest that neither patient demographics nor wound type influenced the bacterial composition of the chronic wound microbiome. Collectively, these findings indicate that empiric antibiotic selection need not be based on nor altered for wound type. Furthermore, the results provide a much clearer understanding of chronic wound microbiota in general; clinical application of this new knowledge over time may help in its translation to improved wound healing outcomes.