Journal Article Annotations
2022, 2nd Quarter

Critical Care

Annotations by O. Joseph Bienvenu, MD, PhD
July, 2022

Psychiatry’s role in the prevention of post-intensive care mental health impairment: stakeholder survey.
Barriers and facilitators to resuming meaningful daily activities among critical illness survivors in the UK: a qualitative content analysis.

PUBLICATION #1 — Critical Care

Psychiatry’s role in the prevention of post-intensive care mental health impairment: stakeholder survey.

Ewa D Bieber, Kemuel L Philbrick, Jenna B Shapiro, Lioudmila V Karnatovskaia

Abstract: BMC Psychiatry. 2022 Mar 18;22(1):198. doi: 10.1186/s12888-022-03855-w.

Background:
Many critical illness survivors experience new or worsening mental health impairments. Psychiatry consultation services can provide a critical role in identifying, addressing, and preventing mental health challenges during and after admission to the acute medical care setting. However, psychiatry involvement in the ICU setting is lower than in other hospital settings and the conventional process in many hospitals requires other care providers to request consultation by psychiatry. Despite these differences, no studies have sought ICU provider perspectives on psychiatry consultation’s current and desired role. We aimed to obtain stakeholder feedback on psychiatry’s current and desired roles in the ICU, and potential benefits and drawbacks of increasing psychiatry’s presence.

Methods:
A web-based survey obtained perspectives from 373 critical care physicians and advance practice providers, bedside nurses, physical and occupational therapists, pharmacists, and consultation-liaison psychiatry physicians and advance practice providers at a tertiary care center using multiple choice and open-ended questions. Descriptive information and content analysis of qualitative data provided information on stakeholder perspectives.

Results:
Psychiatry’s primary current role was seen as assistance with management of mental health issues (38%) and suicide risk assessments (23%). 46% wished for psychiatry’s increased involvement in the ICU. Perceived benefits of increased psychiatry presence in the ICU included early psychological support in parallel with medical care, identification of psychiatric factors impacting treatment, and facilitation of family understanding of the patient’s mental state/delirium. An additional perceived benefit included reduction in provider burnout through processing difficult situations and decreasing family psychological distress. However, one concern included potential conflict among providers regarding treatment.

Conclusions:
Those who work closely with the critically ill patients think that increased psychological support in the ICU would be beneficial. By contrast, psychiatry’s current involvement is seen to be limited, perhaps driven by varying perceptions of what psychiatry’s role is or should be.

Annotation

The finding:
The authors surveyed critical care and C-L psychiatry clinicians at Mayo Clinic on the potential benefits and risks of increasing the psychiatry (and/or psychology) presence in the ICU. The risks were minimal (e.g., potential workflow disruption or mixed messages to families), and the potential benefits more evident to providers than bedside nurses (who were more focused on burnout). To the authors’ and my knowledge, this is the first survey of its kind. The responses in “other” slots indicate more interest from critical care clinicians in having psychologists in the ICU, perhaps because of a perception that psychiatrists would be more interested in prescribing medications than facilitating communication and providing basic psychotherapies (perhaps we deserve this sentiment!).

Strength and weaknesses:
I applaud the authors for asking these important questions. The results fit with my C-L experience: e.g., in the past, our psychiatry residents assumed they should not be involved in the care of patients who are delirious or intubated. Notably, proactive psychiatric consultations are occurring and being investigated at institutions like Virginia Commonwealth University (Melissa Bui) and Brigham and Women’s Hospital (now Jordan Rosen), and our rehabilitation psychology colleagues are increasingly interested and involved in this work. This study comes from a single university hospital in the Midwest, and the authors were only able to get about a 1/3 response rate. Nevertheless, these results likely generalize to other ICUs where psychiatric consultations are relatively uncommon.

Relevance:
Psychiatrists and other mental clinicians could certainly make a difference in the outcomes of the critically ill. The current article illustrates some of the attitudinal challenges to making routine C-L psychiatry consults a reality.

PUBLICATION #2 — Critical Care

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

Leslie Scheunemann, Jennifer S White, Suman Prinjha, Tammy L Eaton, Megan Hamm, Timothy D Girard, Charles Reynolds, Natalie Leland, Elizabeth R Skidmore

Abstract: BMJ Open. 2022 Apr 26;12(4):e050592. doi: 10.1136/bmjopen-2021-050592.

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.

Annotation

The finding:
The authors employed a Person-Task-Environment model when qualitatively appraising interviews with critical illness survivors. Though person-related barriers (e.g., depressed mood, physical weakness) have been a focus of prior observational and intervention studies, the authors cast a wider net and enhance our understanding of facilitators of recovery (e.g., matching tasks with patients’ abilities, managing expectations, and explicitly acknowledging progress).

Strength and weaknesses:
The data were collected in the mid-2000s; however, despite advances in critical care medicine, survivors still face the same issues they did at that time. Nevertheless, the original study was not designed to focus specifically on barriers and facilitators in interview. I believe the authors have done the field an immense favor in drawing attention to new variables to consider and address when designing interventions to enhance critical illness survivors’ recovery.

Relevance:
This work is relevant to any mental health clinician who addresses recovery from critical illness. Optimal treatments will likely require more attention to facilitators of recovery (e.g., reframing expectations, providing positive feedback), not simply using “antidepressants” and uninformed psychotherapeutic techniques to help mood and anxiety in this population.