After critical care: Patient support after critical care. A mixed method longitudinal study using email interviews and questionnaires

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Summary

Purpose

To explore experiences and needs over time, of patients discharged from ICU using the Intensive Care Experience (ICE-q) questionnaire, Hospital Anxiety and Depression Scale (HADS) and EuroQoL (EQ-5D), associated clinical predictors (APACHE II, TISS, Length of stay, RIKER scores) and in-depth email interviewing.

Methods

A mixed-method, longitudinal study of patients with >48 hour ICU stays at 2 weeks, 6 months, 12 months using the ICE-q, HADS, EQ-5D triangulated with clinical predictors, including age, gender, length of stay (ICU and hospital), APACHE II and TISS. In-depth qualitative email interviews were completed at 1 month and 6 months. Grounded Theory analysis was applied to interview data and data were triangulated with questionnaire and clinical data.

Results

Data was collected from January 2010 to March 2012 from 77 participants. Both mean EQ-5D visual analogue scale, utility scores and HADS scores improved from 2 weeks to 6 months, (p = <0.001; p = <0.001), but between 6 and 12 months, no change was found in data from either questionnaire, suggesting improvements level off. These variations were reflected in qualitative data themes: rehabilitation/recovery in the context of chronic illness; impact of critical care; emotional and psychological needs (including sub-themes of: information needs and relocation anxiety). The overarching, core theme related to adjustment of normality.

Conclusions

Patient recovery in this population appears to be shaped by ongoing illness and treatment. Email interviews offer a convenient method of gaining in-depth interview data and could be used as part of ICU follow-up.

Introduction

The admission of patients to critical care for supportive treatment of critical illness has been shown to cause significant physical and psychological sequelae (Audit Commission, 1999, Cuthbertson et al., 2004, Cuthbertson et al., 2010, Jones et al., 2001, NICE, 2009). Guidance suggests that critical care services should also address long-term sequelae, including post-traumatic stress disorder, anxiety and depression (NICE, 2009) and long-term consequences of critical illness have family and individual costs including diminished areas of health-related quality-of-life, sleep, reduced ability to return to work and leisure activities (Audit Commission, 1999, Cuthbertson et al., 2010, Graf et al., 2008, Rattray and Hull, 2008); recovery from critical illness may continue to affect patients and their carers, and some extensively so (Adamson et al., 2004). Follow-up services have been established across much of Northern Europe and beyond, to address such issues. There is weak evidence regarding the efficacy of interventions to address emotional and psychological consequences, which can persist for many years (Ringdal et al., 2010, Zetterlund et al., 2012). Research in critical care follow-up centres on post-traumatic stress disorders, anxiety/depression and physical function (NICE, 2009). Follow-up also has a role in patients seeking to make sense of their ICU experiences (Storli and Lind, 2009) and to find reassurance about their experiences (Pattison et al., 2007, Prinjha et al., 2009), although one RCT found no effect on long-term quality of life (Cuthbertson et al., 2010), however there have been criticisms for only using nurses in rehabilitation programmes and a manual-based approach (O’Connor et al., 2009; Wright et al., 2009). However, this study importantly reinforced the longer term consequences of critical care with approximately 25% requiring referral for physical problems and the same number for psychological problems. Whilst revisiting the ICU environment and the use of ICU diaries have been shown to be beneficial to patients as part of the follow-up process, allowing for debriefing and giving patients a way of filling in missing time (Backman and Walther, 2001, Engstrom et al., 2008, Engstrom et al., 2009, Engstrom et al., 2013) and an improved long-term -related quality of life (QOL) (Backman et al., 2010), a gap still exists to explore patient needs for support after critical care and to consider a different model of follow-up.

Section snippets

Models of follow-up

Follow-up is traditionally face-to-face, however in an era increasingly led by Internet activity (United Nations Statistics Division, 2013) there is a role for exploring other methods. The value of telephone follow-up in managing issues after hospital discharge has not been fully established (Mistiaen and Poot, 2006). Email is a burgeoning area of follow-up and it has been used in hard-to-reach or vulnerable populations such as in HIV (Cook, 2012). Several Cochrane reviews of research in the

Email as a research method

Email interviewing is a research method that allows flexibility in participation for users (Kivits, 2005, Meho, 2006, O’Connor et al., 2008) which is novel in healthcare research (Bjerke, 2010). Email has particular value in generating qualitative research data. Online or email-based surveys as research methods have been around since the early 1990s, but using email interviews as a primary method for obtaining in-depth qualitative data is relatively novel. Internet usage across the world has

Design

A non-interventional, mixed-method, longitudinal study to explore the experiences and needs of patients discharged from critical care using questionnaires and interviews. Associated clinical predictors were triangulated with questionnaires and data from in-depth qualitative interviews via The use of mixed-methods allows quantitative results to be further explained by themes from qualitative data gathered thus drawing conclusions beyond the use of one method alone (Creswell and Plano Clark, 2007

Methods

Ethical approval was obtained from a regional health Research Ethics Committee. Patients meeting the inclusion criteria were approached by a member of their clinical care team and a brief outline of the study given; written information sheets were then given to willing patients by a nurse researcher and the study discussed in greater detail. Written informed consent was obtained from all participants and the research was carried out in compliance with the Helsinki Declaration (WMA, 2013).

All

Results

A study flowchart for the 77 participants can be seen in Fig. 1.

Discussion

The aim of this study was to explore the experiences, needs and outcomes over time of patients discharged from critical care, with the unique aspect being the use email, not previously used in this population, to gather the in-depth data with which to triangulate the clinical and questionnaire data. The findings showed how after discharge quality of life showed an initial improvement at six months, as reflected in general ICU literature, (Cuthbertson et al., 2010, Dowdy et al., 2005, Oeyen et

Conclusions

Recovery, measured by QoL and anxiety and depression scores, and reflected in the in-depth qualitative data, initially improves over time as might be expected, however this levelled out after six months, even decreasing in anxiety/depression. However, in this patient group recovery from critical illness is shaped by ongoing illness and treatment of cancer, and the need for adjustment to a new normality of living with and beyond cancer. Email interviews offer a convenient method of gaining

Acknowledgements

The authors would like to thank Dr Tim Wigmore for his support, and Karen Thomas for her statistical advice.

Funding: This study was part-funded by a European Society of Intensive Care Medicine/European Critical Care Research Network Edwards Nursing Science Award.

Conflict of interest: No conflict of interest to declare.

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