Comparative critical review of two research pieces

¶ … Nursing: Comparative Critical Review

To analyze the most pertinent data from a review of literature concerning the problems following discharge after intensive care during the recovery period in the weeks following the discharge of the patient. Further to make a comparative critical review of the work "Problems Following Discharge after Intensive Care" written by Daffurn et al. (1994) and "Intensive and Critical Nursing Care" written by Scraggs et al. (2001)

Intensive Care Units are present in most institutions of medical care and are for the specific primary purpose of enabling round-the-clock care for the patients that are most ill and most in need of constant and scrutinized care while in the medical care facility. The period following the intensive care stay is often a period of time that the patient remains in the hospital or medical institution however there are those patients who are discharged directly home after a stay in the ICU. This work reviews the material available in relation to those patients discharged directly home and the outcomes that have been reported as well as assessing the aforementioned works of Daffurn (1994) and Scraggs (2001).

I. Review of Articles for Comparative Critical Review

Article One:

According to Daffurn (1994) there is not much information con-cerning the "recovery period in the weeks immediately following discharge" of patients from the Intensive Care Unit of hospitals. A study was conducted over a six-month period in Sydney, Australia during the year of 1991 in effort to "identify and describe the sequele found in patients at 3 months after leaving the ICU." There were 54 patients in the study whose length of stay (LOS) was greater than 48 hours in the ICU. Major findings of the study were that a total of 34% of the patients "had no recollection of their ICU stay" while 16% reported "unpleasant memories, including nightmares and hallucinations" and 27.7% reported "minor complaints." In this study the patients medical specialist had provided the major follow-up service and over 75% of the patients needed further "special assessment or advice." The study concluded that:: "A more comprehensive discharge process is suggested." Daffurn (1994)

Article Two:

The study performed by Scraggs et al. (2001) was conducted in a hospital setting in Sydney, Australia in 2001 in a voluntary participatory project approved by the Ethics Committee of the South Western Sydney Area Health Service and the University of Sydney. The patients in this study were of an average or "mean" age of 51.27 years of age. There were fewer females than males in the study which is consistent with the ratio of the "ICU population with most patients being active prior to admission to the ICU and 44% of patients employed prior to admission." The illness predominant was that of "cardiac disease and hypertension." Further noted in the pretest stage of study was that:

The majority of the patients received antibiotics while n ICU (85%) and 12.9% of the patients required inotropic support due to instability in their cardiovascular status. Another 12.9% of the patients were on continuous veno-venous haemodiafiltration (CFFHD) due to acute renal failure. 34 of the patients had experienced complications due to respiratory (n=16) sepsis or infection (n=17), multiorgan failure (n=3), renal failure (n=2), bleeding (n=4), and other complications (n=8)." Scraggs et al. (2001)

Results of the study found that of the 54 patients 34 of the patients experienced normal sleep patterns after discharge while 15 reported that they were unable to remain asleep due to disturbances and 5 patients were unable to fall asleep. 41 patients reported a normal appetite while 11 reported that their appetite was reduced and 2 patients reported a controlled appetite. Of the 54 patients 17 were not on medications at al while 14 of the patients were n Cardiac medications, 9 patients were taking multiple meds and four patients were taking analgesic medications. In relation to the memory of the patient in relation to the ICU stay 16 of the 54 patients had no memory of the stay whatsoever while 7 had a pleasant recall of the ICU stay and 9 patients claimed an unpleasant recall of their stay in the ICU. Reporting nightmares during the ICU stay were 7 patients while 15 of the patients had complaints of a minor nature. Home support was reported to be "none" by 4 of the 54 patients, while 40 of the patients reported "good" home support and 10 patients reported inability to sleep due to interruptions from home help support. This study also stated that there is very little in existence in the form of scientific studies in relation to patients after being discharged home from the Intensive Care Unit. Scraggs et al. (2001)

II. Review of Available Literature:

In the study performed by the Faculty of Nursing and Health, Centre for Clinical Practice Innovation, Griff University, Bundall, Queensland, Australia, Chaboyer (2003) writes that many patients studied over a three-year period relating to "ICU patients long-term experiences after being discharged from the hospital" identified that most of the patients had been discharged from the ICU to return home and that many of the patients had experienced resulting problems with "mobility, disability and fatigue." Further noted was "changes in employment status" as well as the "need for financial assistance." The study resulted in further research studies being undertaken in relation to the patient following ICU discharge. Chaboyer (2003)

In a study performed by Evangelismos Hospital in Athens, Greece by the Department of Critical Care Medicine,. Dimpoulou et al. (2004) writes was with the stated objective "to evaluate health-related quality of life and disability in multiple-trauma patients requiring intensive care unit management." Findings of the study were that 64 of 87 patients experienced a problem in one of the six areas related to "subjective health status" with the most "prevalent complaint" being related to "subjective health status" in the form of "somatic subdimensions with emotional functioning also affected." The stated conclusion of this study is that "the majority of survivors of major trauma exhibit considerable levels of disability and impairment in health-related quality of life. Global injury severs score and degree of brain trauma determines functional limitations." Dimpoulou et al. (2004)

In a study performed by the Critical Care Medicine Unit at Flinders University in Adelaide, SA Australia, Maddox (2001) writes that "While appropriate referrals to community services upon discharge home may address the physical needs of former intensive care patients, the psychological needs may be overlooked." This study is descriptive of the period of recovery following discharge of the patient home after ICU care in relation to their significant others and targets identification of factors influencing the patient's recovery period. The method of study was through semi-structured interviews with five patients and four significant others and was conducted between six and fifteen weeks following the patient's discharge from the ICU. Factors that influenced the recovery period were " individual attitudes, prior experiences, the ICU experience and support of family and friends." The study found that "attention to physical needs and care often mask the psychological support received, particularly from family members" and that "despite awareness of community supports, patients were generally reluctant to avail themselves of any of these services." Maddox (2001)

In a study performed by the School of Healthcare Studies, University of Leeds, Highroyds Hospital in the United Kingdom with the stated objective of "examination of long-term psychological consequences for survivors of intensive care" Perrins (1998) writes that the one-year study was a follow-up of 72 patients after having been discharged from the ICU at St. James University Hospital in Leeds. The aim was assessing the patient in terms of "sense of well-being at specified intervals" after having been discharged from St. James University's ICU in Leeds and as well was inclusive of making identification of variables in the ICU environment that may be attributed to or influence the recovery of the patient in psychological terms. The study assumes and indicates that the different variables among the individual patient in terms of "type of illness," recall of the patient as well as other factors greatly determine the recovery outcome of patients. This study expands the perception of post-ICU psychological and quality of life studies. Perrins (1998)

In a highly relevant study conducted by Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Medical School, Mayo Clinic in Maryland, Finkielman et al. 2003 writes that the objective of the study was focused toward the fact that each year in July inexperienced residents begin to care for patients admitted to the ICU and the determination of the patient's outcome due to the impact either negatively or positively resulting from the inexperienced resident in terms of patient care delivery. "76.7% of patients were discharged home while 15.1% were stated discharged to other facilities" Finkielman et al. (2003). Adjustments were made for potentiality of variable confounds and no noted differences in admission rates for that time period were found. Conclusions were that patient admission to ICU during July was in no way associated with hospital mortality rate increase or ICU stay length. Finkielman et al. (2003)

In a study conduction by the Department of Anesthesia and Intensive Care at the Haukeland University Hospital in Norway which was a follow-up of after intensive care with objectives of research of "health problems, quality of life, functional status, and memory" Kvale et al. (2003) following intensive care. Findings in brief were that further research is needed to fully understand exactly how the many psychosocial and physical possibilities of problems after a stay in the ICU are specifically related to and resulting from that stay. Kvale et al. (2003)

In the study "Leaving the Intensive Care Unit: A Phenomenological study of the Patient's Experience" conducted by the Belfast School of Nursing and Midwifery at Queen's University in the UK, McKinney et al. (2002) states that the study was focused on that which is termed "relocation stress" and is a phenomenon not examined fully or thoroughly understood in relation from the patient's transfer from ICU and stated that greater continuity of care for those recovering from critical illness. McKinney et al. (2002). Although this study focused on transfer from ICU to ward, the findings are relevant in that assuredly the discharge transfer of the patient from ICU to home is just as large an adjustment as from ICU to ward for the recovery of the critically ill patient in both psychological and physical terms.

The study entitled "Intensive Care Unit Survivors Have Fewer Hospital Readmissions Days than other Hospitalized Patients in British Columbia" conducted in 2004 and reported by Keenan et al. (2004) at St. Paul's Hospital Centre for Health Evaluation and Outcome Sciences was conducted with the objective of making a determination of the association between the number of hospital readmissions and those that were ICU readmissions as well as finds as to number of readmission days. The study was of 23, 859 patients admitted to the ICU and 40052 patients admitted to the hospital but not admitted to the ICU. No interventional methods were applied. Results show that ICU had 0.66 readmissions per year and 5.29 readmissions days within a year compared to 073 per year and 5.48 per day for the non-ICU group. Conclusions were that ICU patients surviving admission have fewer hospital readmissions than former patients that did not have a prior intensive care unit stay. Keenan et al. (2004)

In a brief review of various studies of specified medicine categories it was found through a study investigating the value of information on clinical features and intensity of treatment activity in the ICU in predicting the need for further interventional care after discharge of the patient from the ICU findings were that complications in sub-ICU patients "younger than the age of 50 are less likely" than in other patients.

Demonstrated was a linear logistic regression analysis of predictive values for sub-ICU complications and findings were that age, increased risk X 10 for patients over 50 not within the set "predetermined limits." Berardino (2000) in a separate study conducted by the Department of Intensive Care at Sir Charles Gardiner Hospital in Perth Western Australia entitled "Patient's Dreams and Unreal Experiences Following Intensive Care Unit Admission" Roberts et al. states that "Dreams and unreal experiences occur commonly in critically ill patients admitted to intensive care unit." The study is performed with 31 patients in relation to the "patient's subjective recall 12-18 months" after the ICU stay. Findings were through "semi-structured interviews that 74% of patients" who were in the ICU 3 days or longer "reported dreaming, with the majority" also reporting "frightening hallucinations" however only two of the total 31 patients were found to have sustained long-term negative psychological sequelae but short terms impacts may have not been discovered. Roberts et al. (2004)

Important and highly relevant findings are revealed in the following study as to the value of providing both oral and written instructions to ICU patients upon their being discharged from the ICU to home. In this study entitled "Written and Verbal Information vs. Verbal Information Only for Patients Discharged from Acute Hospital Settings to Home" stated is that:

Provision of verbal and written health information significantly increased knowledge and satisfaction scores." Johnson et al. (2003)

The study notes that this is particularly vital procedure in situations of educational lack or other speech or language associated complications. For example the provider of care in a large city inclusive of many spoken languages would be urged to give both oral and written instruction to the patient for aftercare upon ICU discharge.

Strahan et al. (2003) states that:

Follow-up of patients discharged from the intensive are unit is recommended as a means of service evaluation (Department of Health 2000 Comprehensive critical Care: A Review of Adult Critical Care Services) in order to monitor the quality of the services provided."

One final aspect for review in this work is that of the caregiver's responsibilities and the accompanying responsibilities of the ICU and staff in preparing the caregiver through instructional assistance at the time of the ICU patient's discharge. In a study entitled "Caregivers of ICU Patients Discharged Home: What Burden do they Face?" Chaboyer (2001) writes that:

It is therefore essential that all nurses involved in ongoing management of the ICU patients have an understanding of the caregivers role, and consider both the patient and his/her carer in the discharge planning process." Further stated is that "caregivers experience a substantial burden which is associated with the complexity of the patient's physical and psychological impairment and complex technology. To enable the impact of the caregiver further research is needed to more fully explore, examine and measure the factors involved in caring for IU patients postdischarge." Chaboyer (2001)