Page 96 - ACCCN's Critical Care Nursing

Recovery and Rehabilitation 73

Research vignette, Continued

psychological outcome, and providing a factual account of their intervention patients and 48% of the controls identified their ICU
ICU stay intuitively appears to be a sensible approach to improve experience as a traumatic event. Most patients (87%) in the inter-
this outcome. This reviewed paper reported an international multi- vention group received their diaries at randomisation, and shared
centre randomised controlled trial evaluating the effect of a patient these with others. On the whole patients found both text and
diary on the incidence of new cases of post traumatic stress disor- photographs in the diaries helpful.
der (PTSD) in patients with an ICU stay of 72 hours of more and The study has a number of strengths. The sample size was large for
mechanical ventilation of 24 hours or more.
an ICU study and there was limited attrition. Appropriate measures
Participants were patients admitted to one of 12 ICUs in six Euro- were used that addressed the DSM-IV criteria. Administration of
pean countries. Inclusion and exclusion criteria were clearly the PDS varied according to whether a patient could return to the
described and good rationale given for these. Patients were hospital, and for those who could not, the PDS was administered
excluded with preexisting psychotic illness or if they had been by telephone. As the authors stated, it would have been beneficial
previously diagnosed with PTSD. All participating units had experi- if the PDS had been administered on two occasions: at 1 month
ence of using patient diaries and these were standardised through and 3 months. However this was not thought feasible given the
a designated diary group on each unit. One of the strengths of patient effort to complete the measure.
this paper was the use of standardised measures previously used
in the intensive care population to assess patients’ memories of The international focus suggests good generalisability within
intensive care (ICU Memory Tool), posttraumatic stress symptoms Europe but this would have been strengthened if a brief descrip-
(Post-Traumatic Stress Syndrome 14 [PTSS-14]) and posttraumatic tion of each unit had been provided and the breakdown of recruit-
stress disorder (Posttraumatic Diagnostic Scale [PDS]). Patients ment to each unit had been presented. However, word limits in
were recruited to the study approximately one week after dis- journal papers often do not allow for this. The diary as an interven-
charge from ICU and randomised about one month later after tion was well developed and standardised and the use of a limited
baseline completion of the PTSS-14. Individuals in the control number of researchers enhanced the validity of the findings. Clini-
group received their diaries after completion of the outcome cal studies have a number of challenges. It is often important to try
measure (around 3 months after discharge), while those in the to reflect practice that is feasible and practical within a clinical
intervention group received theirs as soon as requested. The setting and this study acknowledges this.
diaries were introduced to the patient by a research nurse or The findings from this study are encouraging and add to our
doctor. The PDS was the main outcome measure, assessed all des- understanding of the effectiveness of using patient diaries. A
ignated DSM-IV criteria of PTSD and was administered as a diag- smaller UK-based study had also found a reduction in anxiety and
nostic interview. depression in patients who had received diaries. Both studies
161
evaluated the effectiveness of diaries over a relatively short period
Three hundred and fifty two patients were recruited over a of time. PTSD may have late or delayed onset, has been shown not
12-month period, and 322 completed the three month follow-up to reduce over time and in fact tends to be enduring. It is therefore
assessment (control n = 160: intervention n = 162). Group equiva- important to be confident that any intervention causes no harm to
lence was established although there were more females in the patients and further study that explores the longer-term effect of
control group. Findings demonstrated that patients who had been the diaries would be beneficial.
exposed to a diary were less likely to be diagnosed with new onset
PTSD: 5% versus 13% (chi-squared = 7.15, P = 0.02). There was Importantly, this study identified an issue common to many ICU
however no overall difference in the PTSS-14 scores between 1 and studies: it demonstrates that these ‘blanket’ interventions tend not
3 months between control and intervention patients (Mann to be effective in this patient group but rather we need to target
Whitney U P = 0.737). A post-hoc analysis did identify a difference those patients who will benefit from either a physical or psycho-
between groups in the small number of patients who ‘triggered’ a logical intervention. Larger studies that allow subgroup analysis
cut-off score in the PTSS-14 at 1 month. Importantly 43% of the are necessary to do this.

Learning activities
1. Patients transferred from ICU to the ward may have complex Items 4–5 relate to the case study on p. 72.
care needs. In your hospital, who assesses these physical, psy- 4. How and when should Mr Gilardi have been screened or
chological and cognitive needs and ensures that appropriate assessed specifically for PTS symptoms?
health professionals become involved in the patient’s care? 5. Suggest a plan of care that might have minimised or prevented
When does this assessment take place? Mr Gilardi’s ongoing psychological distress.
2. Review the evidence of PTSD assessment and management for
patients after a critical illness and intensive care admission.
3. What are the educational implications for staff in relation to
supporting the psychological problems patients experience
after ICU?