There are limited cross-sectional data regarding goals of care documentation and palliative care practices in intensive care units (ICUs). This point prevalence study describes documentation of goals of care, approach to limitation of life-sustaining therapies, and palliative care practices in Australian and New Zealand ICUs. (i) to describe documentation of goals of care of patients in the ICU and (ii) to describe palliative care practices in the ICU. multicentre, binational, point prevalence study was conducted. All adult patients admitted to 49 participating ICUs at a prespecified date and time were identified and followed up for 24 h. Primary outcome measures were documentation of goals of care, treatment limitations, and palliative care practices. 649 patients were observed from 49 participating ICUs. Goals of care were documented in 444 out of 649 (68%) patients, with 74% (327/444) of these patients for full active management. Ninety-six patients (21%) were for active management with limitation of life-sustaining therapies, and 21 (5%) patients were for palliative care only. The most frequently withheld treatments were cardiopulmonary resuscitation (90%, 86/96), followed by invasive ventilation (50%, 48/96). ICU mortality was highest in patients who received palliative care only (71%, 15/21), followed by those who were for active management with limitation of life-sustaining therapies (27%, 26/96). Twenty-six (8%) patients who were for full active management died in the ICU. Among the patients who were for palliative care only, analgesics and sedatives were administered in 67% and 52% of these patients, respectively. Of the 49 participating ICUs, 29 (59%) had a defined policy or protocol for bereavement follow-up. One-third of patients admitted to the ICU did not have goals of care documented on the study day. Most patients were discharged alive from the ICU. Withholding of certain life-sustaining therapies was associated with increased mortality. Patients who received palliative care in the ICU were provided with symptom management, and bereavement follow-up was provided in two-thirds of participating ICUs.
Voluntary assisted dying (VAD) is legal in most of Australia. Despite growing societal acceptance, clinicians' views remain mixed, particularly in critical care. The aim of this study was to identify and describe factors influencing critical care nurses' support for and willingness to participate in VAD. convergent mixed-method study was undertaken involving (i) an online survey; (ii) individual interviews; and (iii) integration. Critical care nurses were recruited through multiple Australian nursing organisations. Forty-two critical care nurses completed the survey. Over half (57.1%, n = 21) provided end-of-life care at least monthly, 76.2% (n = 32) had at least some knowledge of VAD, and 92.9% (n = 39) were supportive of VAD. Almost all (97.6%, n = 40) were willing to participate in VAD by providing care, advice, or support to a person requesting VAD (97.6%, n = 40), even if family members did not agree (92.7%, n = 38), to care for a person after taking the VAD substance (92.7%, n = 38), and to be present at death (92.7%, n = 38). Willingness reflected respondents' support for patient choice, autonomy, and alignment with professional obligations and personal values. Critical care nurses' cultural beliefs, religion/spirituality, and workload concerns were less important. Eight critical care nurses were interviewed, providing greater detail about VAD in the intensive care unit (ICU) with three themes identified: (i) the complex context, describing tensions with the momentum of ICU care; (ii) if it's the person's wishes, upholding patient autonomy and choice; and (iii) VAD fit and function, reflecting scope of practice and legal concerns and the essential skills for participation. Nurse practitioners were universally regarded as possessing the skills and relational qualities necessary for VAD participation. Critical care nurses showed strong support for VAD, and a willingness to provide VAD-related care, grounded in professional values and commitment to patient autonomy. Policy and practice frameworks formally recognising critical care nurses' role in VAD in the ICU are essential.
The aim of this study was to examine the current perspectives and experiences of nurses regarding their role in the care of chronically critically ill patients in outpatient intensive care facilities in Germany. Significant advances in intensive care medicin hav led to improve patient survival rates. However, patients are often left with chronic impairments as a result. Many patients who have undergone long term ventilation in the ICU require complex follow-up care in specialist facilities. The day-to- day work of nurses in outpatient intensive care facilities is demanding and can be associated with considerable stress. A qualitative descriptive design was used. Qualitative data were collected through audiorecorded semistructured interviews with a convenience sample of nurses from outpatient intensive care facilities in Germany between January and August 2024. Themes were identified through thematic analysis conducted by three researchers. This interview study included 15 nurses (three men and 12 women) from outpatient intensive care services in Germany. Saturation, the point at which further interviews no longer provided any new information, was reached after the tenth interview. Three key themes were identified: (i) working conditions in outpatient intensive care facilities: the interviewed reported a manageable workload; (ii) possible ways of caring for the chronically ill and meeting their needs: the nurses interviewed reported on opportunities and ways of providing individualised, patient-centred care; and (iii) sense of purpose regarding individualised care: good working conditions enable nursing staff to work in accordance with their ethical standards. In this qualitative study of nursing experience of outpatient intensive care, nursing staff describe patient-centred care and the challenges they encounter when treating patients in outpatient intensive care facilities. In this context, strategies that incorporate nursing ethics and relationship development are required. The nurses interviewed found their work in outpatient intensive care fulfilling, which improved their motivation.
Critically ill patients experience high levels of psychological distress; however, the recognition and management of psychological distress in the intensive care unit (ICU) remain underexplored. A concept analysis of psychological distress exists for some patient populations but none in critical care. The aim of this concept analysis was to clarify the contextual character of psychological distress in ICU patients, thereby improving recognition and management practices. Rodgers' evolutionary approach aided a deeper examination of psychological distress in the critical care literature, identifying its surrogate terms, related concepts, attributes, antecedents, consequences, and implications for nursing practice and scholarship. Databases searched included CINAHL, PsycINFO, and MEDLINE. Additional searches were performed in Google Scholar and through citation chaining of relevant articles. A coding sheet was used to organise ideas and phrases from the interdisciplinary health literature for inductive analysis. A total of 35 articles were included in the analysis, based on data saturation. The interdisciplinary literature revealed two surrogate terms (emotional distress and acute ICU psychological stress), one related concept (distress), four antecedents (impaired adaptation to stressors, ICU context of care, demographic and coping skills, and social support systems), and four defining attributes (traumatisation and acute affective reaction, distorted cognitive appraisal, feelings of dehumanisation and disconnection, and affecting the patient-family dyad). Consequences of the concept include chronic or long-term psychological distress, post-intensive care syndrome, poor health-related quality of life, and psychosocial functioning. Psychological distress in critical care may partially be a social and structural consequence of increased pace of care in the ICU. Critical care patients and survivors could be evaluated for psychological distress and be referred to a psychologist for counselling if needed. This paper provides a novel understanding of psychological distress in critical care, highlighting its unique features and the necessity for an interdisciplinary approach to achieving patient emotional safety. These insights lay the foundation for future research and policy development in critical care settings. There is no study registration number.
Intensive care nurses face challenging work environments and experience more moral challenges, which can affect their work engagement. Moral resilience may reduce the risk of such adverse outcomes. While the importance of enhancing nurses' mental health for care quality is well established, research on the relationship between perceived practice environment, moral resilience, and work engagement is still lacking. The aim of this study was to assess the practice environment, moral resilience, and work engagement among Chinese intensive care nurses and to examine whether moral resilience mediates the association between the practice environment and work engagement. A convenience sampling method was used to select intensive care nurses from six tertiary first-class general hospitals in Henan province as participants from December 2024 to January 2025. The General Demographic Questionnaire, Practice Environment Scale of the Nursing Work Index, Rushton Moral Resilience Scale, and Utrecht Work Engagement Scale (UWES-9) were used as survey tools. The mediating effect model was constructed using Amos 23.0 software. A total of 284 intensive care nurses were surveyed. The moral resilience score was 46.38 ± 7.26, the practice environment score was 96.40 ± 18.42, and the work engagement score was 34.94 ± 10.80. All three variables showed positive correlations. Moral resilience partially mediated the relationship between perceived practice environment and work engagement, with a mediating effect size of 0.053, accounting for 5.59% of the total effect. This study highlights that the perceived practice environment for intensive care nurses can enhance their self-reported work engagement and that moral resilience can further boost this engagement. Nursing administrators should focus on building support systems and optimising the environment. This involves enhancing the intensive care unit's practice environment and providing moral resilience training to help nurses maintain their mental health.
The optimal "dose" of rehabilitation interventions in patients who are critically ill is unknown due to gaps in the literature. One of the challenges with determining dose is the lack of a feasible method for measuring the intensity (i.e., patient effort) in patients who are critically ill receiving rehabilitation interventions. Percentage of heart rate reserve (%HRR) may offer an objective method to quantify the intervention intensity in this population. The aim of this study was to evaluate the feasibility of using %HRR to measure intensity during physical therapy (PT) sessions in the intensive care unit. This was a retrospective observational study conducted in the medical intensive care unit at one academic medical centre. The sample included 106 consecutive adults admitted for >24 h, mechanically ventilated, and collectively receiving 765 PT sessions between June 1, 2021, and January 31, 2022. The %HRR was calculated as (peak heart rate - resting heart rate)/(predicted maximum heart rate - resting heart rate). Mobility level was assessed using the Johns Hopkins Highest Level of Mobility score, a one-item scale with eight ordinal responses scored based on highest level of mobility achieved during a PT session. Of 765 PT sessions, the %HRR could be calculated for 515 (67%) sessions in which patients' heart rate increased during the session. The median (interquartile range) %HRR per patient was 10% (6-18%), with 381 (74%) of PT sessions consisting of bed activity and sitting at the edge of the bed. The Spearman's rank correlation demonstrated a weak relationship between %HRR and Johns Hopkins Highest Level of Mobility (rho = 0.17; 95% confidence interval: 0.09 to 0.25, p = 0.0001). This exploratory analysis found that %HRR could be calculated in 67% of PT sessions. Further studies are needed to determine if %HRR is a feasible and valid measure of rehabilitation intensity (i.e., patient effort) for PT sessions among patients who are critically ill.
Patient and family engagement (PFE) in research can enhance the relevance of research undertaken, methodology used, and interventions designed. The practice and extent of PFE undertaken in critical care research is broad and relatively undefined. The aim of this review was to identify the level of PFE in critical care research, according to the International Association for Public Participation Spectrum (IAP2) tool, including where it occurred in the research lifecycle and the impact PFE had on research undertaken. We conducted a scoping review to synthesise the field and provide recommendations to improve reporting of PFE. This scoping review was registered on the International Platform of Registered Systematic Review and Meta-Analysis Protocols and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. We limited the search to 2016-2025 and searched five databases: OVID Medline, OVID Embase, PubMed, CINHAL, and Web of Science. Studies in critical care that reported PFE with one or more levels of the IAP2 tool were included in this review. Forty-seven studies met inclusion criteria. All studies engaged patients and families at the level of "consult" on the IAP2 tool, and few studies (13/47, [28%]) included PFE at all levels of the IAP2 tool. PFE occurred in the initial stages of the research lifecycle for all studies. Only 10 studies engaged patients and families at all stages of the research lifecycle (10/47 [21%]). Nineteen studies (19/47, 40%) reported at least one impact on the research as a result of PFE. This review found that studies typically engaged patients and families to "consult". Most engagement activities occurred during the design phase of the research lifecycle. Studies with higher levels of engagement led to greater involvement across the research lifecycle and were more likely to report an impact on the research.
Critical care outreach teams provide early intervention in response to clinical deterioration on hospital wards to improve patient safety and reduce serious adverse events. A critical care outreach physiotherapy (CCOPT) service was developed to provide early physiotherapy intervention for patients identified at risk of respiratory deterioration. The aim of this study was to describe the clinical service provided by the CCOPT, determine its feasibility and sustainability, explore patient characteristics, and report interventions provided and outcomes of the population referred. Single-centre, retrospective, observational cohort study was conducted including patients referred to the CCOPT service between July 2019 and December 2023. Demographics, referral characteristics, physiotherapy interventions, and patient outcomes including hospital length of stay, discharge destination, and in-hospital mortality were collected. There were 209 patients referred (median [interquartile range] age: 73 [65, 84] years, 66% male), predominantly admitted with trauma (n = 74, 35%). The most common reason for referral was increasing oxygen requirements (n = 91, 44%). Referred patients, triaged as urgent, were reviewed within a median of 30 [13, 45] minutes. Physiotherapy interventions were commenced in 86 (41%) patients, most commonly involving airway clearance techniques (n = 34, 40%) and initiation of intermittent continuous positive airway pressure (n = 30, 35%). Subsequent admission to intensive care occurred in 14% (n = 29) of cases. Hospital length of stay was a median [interquartile range] of 15 [9, 28] days, and 46% (n = 97) of patients were discharged to their prior place of residence. In-hospital mortality of the cohort referred to CCOPT was 27% (n = 57). Physiotherapy is an emerging component of the critical care outreach team. The CCOPT service provided rapid responses to at-risk patients with respiratory deterioration in a ward environment of whom few were admitted to the ICU.
Extracorporeal membrane oxygenation (ECMO) is a type of mechanical circulatory support that is increasingly utilised for severe cardiorespiratory failure in the intensive care unit (ICU) setting. ECMO is resource-intensive, and as a result, the development of ICU-led ECMO teams has provided opportunities for specialist nursing roles and new care delivery models. The aim of this study was to explore and describe the roles and responsibilities of a novel ECLS-APNT nursing team (ECLS-APNT) in a high-volume ECMO ICU. A descriptive qualitative design was applied using a combination of semistructured interviews and confirmatory observation in the clinical ICU setting. The study was conducted in a tertiary ICU in Melbourne, Australia, which provides specialist statewide referral services for ECMO, mechanical circulatory support, and heart and lung transplantation. The ICU admits over 3000 adult and paediatric patients per year, caring for more than 100 ECMO supported patients per year. The ICU provides both venovenous and venoarterial-including extracorporeal cardiopulmonary resuscitation-modes of ECMO. The ECLS-APNT members participated in this study. An inductive approach to content analysis was utilised to identify themes. Six semistructured interviews and 23.5 h of direct observation of the ECLS-APNT were conducted. Five themes concerning the roles and responsibilities of the ECLS-APNT were identified from the interviews and direct observation: (i) internal responsibilities; (ii) external responsibilities of working in an ECMO referral ICU; (iii) beyond ECMO support; (iv) care transitions from clinical deterioration to weaning, bridge-to-transplant, or end of life care; and (v) governance and service quality enhancement to ensure the provision of a "24/7" service. The ECLS-APNT's roles and responsibilities are not limited to the patient-circuit interface. Their innovative-driven practices extend into strategically balancing localised centre needs with statewide service demands such as clinical governance and supporting care transitions (e.g., bridging from ECMO support to transplant).
Across the world, there is increasing recognition of the importance of engaging with and involving patients, family members, and members of the public in the design, delivery, and dissemination of clinical research. This reflects the value of grounding research in lived experience, thereby ensuring the relevance and integrity of the research. In this review paper, we seek to provide an up-to-date review of patient and public involvement and engagement in critical care clinical research. Our review is informed by a targeted MEDLINE search and author experience, including that of a critical care patient research collaborator. We start by providing a definition of patient and public involvement and describe its uptake in critical care research across the world. We describe how patients, family members, and members of the public are now increasingly becoming involved in critical care research through setting the research agenda (e.g., through research priority setting exercises), in making research funding and regulatory decisions, and as key collaborators in the design, delivery, and dissemination of individual research projects. We highlight the opportunity for improved reporting of this involvement and engagement in study reports. Finally, we identify potential barriers to patient and public involvement and engagement in critical care research before identifying solutions by drawing on personal expertise and published evidence.
Psychological distress is common after critical illness and can result in long-term psychological morbidities. Early psychological support in the intensive care unit (ICU) may mitigate these effects, yet ICU psychology services remain uncommon in Australia, and little is known about their implementation. Building on the Psychology in Intensive Care Unit Protocol (PICUP) pilot study, further refinement requires understanding the perspectives of those who experienced the service. This study qualitatively explored (i) how critical care survivors experienced early psychological screening and intervention; (ii) ICU clinicians' views on the role and value of the psychology service; and (iii) facilitators and barriers to integrating it into routine ICU practice. A qualitative descriptive design was used at a metropolitan Australian ICU where the PICUP model had been implemented. Purposive sampling identified PICUP participants who received psychological support during their admission and clinicians involved in their care. Semistructured interviews were conducted with 16 patient participants and 10 clinicians. Interviews were audio recorded, transcribed verbatim, and analysed using reflexive thematic analysis. Patient participants described critical illness as a traumatic and multifaceted experience and viewed psychological support as meaningful when accessed, though many reported limited recall and unmet needs for continuity beyond the ICU. Tailoring support to individual readiness was seen as essential. Clinician participants considered psychology integral to holistic ICU care, with benefits for patient engagement, recovery, and management of complex presentations. They also identified value for significant others and staff. However, clinicians perceived unclear referral pathways, low service visibility, limited psychology resources, and the inherent complexity of the ICU constrained implementation. Patient and clinician participants viewed the ICU psychology service as acceptable and valuable but under-resourced and insufficiently embedded. Their perspectives clarify how the service is understood in practice and what needs strengthening for effective implementation. Findings provide direction for refining the PICUP model and guiding the development of a sustainable approach to the inclusion of psychologists in Australian ICUs.
Arterial catheters are widely used in critically ill patients for continuous blood pressure monitoring and frequent blood sampling. Maintaining catheter patency is essential to avoid occlusion, inaccurate readings, and unnecessary reinsertion. Evidence regarding the superiority of heparinised saline over normal saline remains inconsistent. The aim of this systematic review and meta-analysis was to compare the effectiveness and safety of heparinised saline versus normal saline flushing solutions for maintaining arterial catheter patency in intensive care units (ICUs). A comprehensive search of PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) databases was performed up to June 2025. Only randomised controlled trials comparing heparinised saline and normal saline for continuous arterial catheter flushing in ICU patients were included. The primary outcome was catheter occlusion; secondary outcomes were catheter patency duration, platelet count, and activated partial thromboplastin time. Risk of bias was assessed using the Risk of Bias version 2 tool, and certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Sixteen randomised controlled trials, including 6385 patients, were included. Pooled analysis of 13 trials showed that heparinised saline was associated with a lower risk of arterial catheter occlusion than normal saline (risk ratio: 0.64; 95% confidence interval: 0.50-0.84; I2 = 20.6%). However, prediction intervals crossed unity, and meta-regression demonstrated attenuation of effect in more recent studies. Certainty of evidence was rated low. Heparinised saline was associated with a modest prolongation of catheter patency duration (+12.5 h; 95% confidence interval: 1.43-23.50), while no significant differences were observed for platelet count or activated partial thromboplastin time. Safety outcomes were inconsistently reported, and included trials were not powered to detect rare adverse events. Heparinised saline was associated with reduced arterial catheter occlusion in pooled analyses, but this effect diminished over the years and may not translate to contemporary ICU practice. Further contemporary, well-designed trials are needed to clarify whether selected high-risk populations may derive meaningful benefit.
There is a wealth of studies about nurses' moral courage (MC), resilience, injury, and distress. However, the mediating roles of various moral constructs among their relationships remain understudied, specifically in intensive care unit (ICU) nurses. The aim of this study was to examine the mediating roles of MC, resilience, neutralisation, and injury among their associations. A cross-sectional and correlational study was conducted. Participant ICU nurses were consecutively recruited from five hospitals with adult ICUs in Saudi Arabia. Five standardised self-report scales were employed to collect data. The covariance-based structural equation modelling analysis was used to determine significant paths among the study variables. Mediation analyses showed that MC had statistically significant indirect association with moral neutralisation (MN) (β = -0.05, p = 0.003) and moral distress (MD) (β = -0.11, p = 0.001) via the mediation of moral resilience (MR). MR had indirect association with moral injury (MI) (β = 0.04, p = 0.005) and MD (β = -0.04, p = 0.014) through the mediating effects of MN and MI, respectively. MI was a mediator between the indirect association of MN and MD (β = -0.03, p = 0.035). MC measured 5.59% of the variance of MR. The 18.34% total variance of MN was contributed by MC and resilience. MC, resilience, and neutralisation measured 7.22% of the variance of MI. Finally, 8.96% of the variance of MD was measured by MR, injury, and neutralisation. MR buffers nurses' MD and supports MC, while MI undermines these effects. MN offers short-term relief but risks long-term disengagement, revealing a complex dynamic of protective and harmful moral factors. Healthcare institutions that employ ICU nurses may need to prioritise resilience training, structured moral support, and culturally sensitive interventions to sustain nurses' ethical integrity and reduce harm from MD and neutralisation.
An intensive care nurse practitioner (NP) role was implemented as a safe alternate model of care (MoC) compared to the traditional intensive care unit (ICU) framework as an innovative model to address current gaps within the MoC and to plan for future medical workforce shortages to establish a sustainable MoC to meet growing demand. The primary purpose of this project was to identify the usefulness and the multidisciplinary team's (MDT's) satisfaction of the intensive care NP role. prospective cross-sectional mixed-method study design was used. The survey was distributed across all staff working in the ICU via the Research Electronic Data Capture platform. Quantitative responses were exported to SPSS for analysis; descriptive statistics were calculated and expressed as means and standard deviations in normally distributed continuous variables. Relationships were calculated using Wilcoxon Chi Square, significance was set at 0.05. Qualitative data underwent a thematic analysis to identify key themes. Overall, the NP was highly rated from the MDT. There were some significant differences between the MDT responses; nurses scored significantly higher than the medical staff when evaluation the NP's incorporation of evidence-based practice (median 10.0 vs 8.0; p < 0.01) and confidence to follow a management plan set out by the NP. Allied health rated the NP's ability to facilitate a discharge significantly higher that nurses did (mean: 9.9, standard deviation: ± 0.38 vs 8.7 standard deviation: ± 2.2; p < 0.01). Five themes were identified during thematic analysis: bridging, continuity of comprehensive patient care, support, advanced clinical skillset, and asset to the unit. The survey demonstrated there was overall high satisfaction with no difference reported between the MDT responses. This reinforces previous findings that NPs can provide safe and effective ICU management and care in collaboration with the MDT.
Psychological distress is common among intensive care unit (ICU) patients, yet current pharmacological approaches carry risks. The aim of this study was to survey ICU clinicians' perceptions of psychological stressors affecting patients, their coping strategies, and the perceived feasibility, benefits, and challenges of implementing virtual reality (VR) interventions in ICU settings. A dual-method cross-sectional survey was distributed to ICU clinicians in Australia and New Zealand between March and May 2025. The survey comprised 5-point Likert-scale and open-ended questions exploring three domains: (i) perceived psychological stressors in ICU patients; (ii) current practices and perceived effectiveness of psychological support interventions, including VR; and (iii) perceived barriers and design recommendations for VR implementation in the ICU. Quantitative data were analysed descriptively; qualitative responses underwent thematic analysis using the NVivo software. Among 143 valid respondents (125 completed), 56.6% were female; 48.3 % were nurses, 46.9% doctors, and 4.8% allied health professionals. Lack of sleep (median: 5 [4-5]), isolation (median: 4 [3-4]), temporal disorientation (median: 4 [3.5-4]), and sensory overload (median: 4 [4-5]) were rated as key stressors. Pharmacological, family communication, and maintaining a calm environment were the most implemented and effective interventions (median: 4 [4-4]). Engagement activities were infrequent, but structured communication with family was rated important (median: 4 [4-5]). The interventions listening to music, watching family videos, and viewing nature scenes (median: 4 [3-4.5]) closely followed. VR was seen as moderately familiar (median: 3 [2-3]) and moderately beneficial (median: 3 [3-4]) but difficult to implement (median: 3 [3-4]). ICU clinicians recommended that the VR content should be personalised, simple, safe, and supporting both patients' emotional needs and ICU workflow integration. ICU clinicians acknowledge the perceived psychological burden of ICU environments and engagement activities were infrequent in ICU patients. They express cautious optimism towards VR as a supportive tool. However, successful implementation requires addressing significant logistical, clinical, and educational barriers.
Survivors of critical illness often have poor health-related quality of life (HRQoL). However, it is unclear what factors are associated with changes in HRQoL after critical illness. The aim of this study was to determine an association between sepsis diagnosis, demographic factors (age and sex), and HRQoL in survivors following critical illness. A secondary analysis of international data from the previously published Standard Issue Transfusion versus Fresher Red Blood Cell Use in Intensive Care (TRANSFUSE Study) Randomised Controlled Trial, an international, multicentre randomised double-blind trial, was conducted. Adult patients admitted to the intensive care unit undergoing transfusion of one or more red blood cell units were included. HRQoL was measured using the EuroQol five-dimension three-level instrument at 180 days post randomisation. Estimates for the EuroQol five-dimension utility value and EuroQol visual analogue scale (EQ VAS) were reported as median difference with 95% confidence intervals. Among 4919 participants, 3459 survived to 180 days, of which 3143 (91%) had complete HRQoL data. There were no significant differences in the utility value and EQ VAS between survivors following critical illness with and without sepsis (utility value difference: -0.02 [-0.04 to 0.00], p = 0.11; EQ VAS difference: -1.17 [-4.35 to 2.02], p = 0.47) or between male and female survivors (utility value difference: -0.01 [-0.03 to 0.01], p = 0.34; EQ VAS difference: -0.94 [-3.06 to 1.18], p = 0.38). Patients aged 50-59 years (-0.07 [-0.12 to -0.03], p = 0.002), 60-69 years (-0.05 [-0.10 to -0.01], p = 0.016), and ≥80 years (-0.07 [-0.12 to -0.02], p = 0.003) had a significantly lower utility value than patients aged 18-29 years. Patients aged 50-59 years (-7.35 [-11.97 to -2.73], p = 0.002), 60-69 years (-6.10 [-11.00 to -1.19], p = 0.015), and ≥80 years (-6.78 [-12.04 to -1.53], p = 0.011) also had a lower EQ VAS score than patients aged 18-29 years. After adjustment for age, comorbidities, and illness severity, sepsis diagnosis was not independently associated with lower HRQoL at 180 days. These findings are consistent with emerging evidence suggesting that long-term outcomes in intensive care unit survivors may be driven predominantly by critical illness rather than aetiology. No significant differences in the utility value or EQ VAS were found by sex. However, there were significant differences in HRQoL by age in survivors following critical illness.
Critically ill adult patients who require arterial puncture for arterial blood gas analysis are exposed to pain. We evaluated the potential effect of a vapocoolant spray on reducing pain in this population. SNOW study was a multicentre, randomised, single-blind, placebo-controlled, assessor-masked, superiority trial conducted in four intensive care units in French hospitals. We randomly assigned critically ill adult patients (aged ≥18 years) to one of two treatment groups (vapocoolant spray or placebo) before an arterial puncture for arterial blood gas analysis. The primary outcome was the intensity of the patient's visual analogue scale rating of pain immediately after the arterial puncture, as assessed by masked assessors. The analysis is reported in the modified intention-to-treat population, which included all randomised patients except those who withdrew or did not consent to continue and those who did not receive their allocated treatment because they met a criterion for ineligibility. The trial was registered on Clinicaltrials.gov with the identifier NCT03973385. From November 12, 2020, to January 12, 2022, 201 patients were randomised to receive either vapocoolant spray (101 patients) or placebo spray (100 patients); 194 received the allocated intervention and 192 were included in the analysis (96 in each allocation group). In the modified intention-to-treat analysis, both the best and worst scenarios for handling with missing data demonstrated that the use of vapocoolant spray was significantly associated with a lower visual analogue scale pain score at the end of the arterial puncture procedure (effect size [Cohen's d]: -0.30 [95% confidence interval: -0.58 to-0.01] and -0.48 [-0.77 to -0.19], respectively). No instances of serious adverse events were reported. In critically ill adult intensive care patients, the use of vapocoolant spray reduced pain during arterial puncture for blood gases, without significant side effects.
Children admitted to paediatric intensive care units frequently require invasive interventions and mechanical ventilation, requiring meticulous sedation management. Optimal care depends on careful titration of analgesics and sedatives, guided by clinician-administered assessment instruments to ensure proper dosing and minimise adverse effects. The State Behavioral Scale (SBS) is one of the two primary instruments recommended to assess sedation in mechanically ventilated children but has not been translated for French-speaking clinical settings or adapted for integration into an electronic health record (EHR) system. The aim of this study was to translate the original English SBS into French and adapt it culturally and digitally. This descriptive study, using a 10-step translation and cultural adaptation process, was conducted following the International Society for Pharmacoeconomics and Outcomes Research Task Force framework for Translation and Cultural Adaptation of Patient-Reported Outcomes Measures. One professional translator and 17 native-speaking expert clinicians participated in this process. The SBS was then adapted for digital use. The translation and cultural adaptation of the SBS ensured conceptual and linguistic equivalence through reconciliation, expert review, and harmonisation. Cognitive debriefing with nine nurses confirmed clarity and usability, leading to minor refinements and a supplementary guidance document. A digital version was developed for integration into the EHR, using selectable descriptors and automated scoring. This adaptation was reviewed by clinical and research experts and validated by the original SBS developer. A linguistically and culturally adapted version of the SBS for the French context has been developed and is ready for EHR integration and psychometric testing. The digitalised French version of the SBS will enable French-speaking settings to perform accurate and standardised sedation assessment in mechanically ventilated children, helping to prevent adverse effects of undersedation and oversedation and improve patient outcomes.
Nurse practitioners are being increasingly integrated into critical care teams. In Western countries, nurse practitioner (NP)-led care yields clinical outcomes comparable to physician-led care. However, no study in Asia has compared intensive care unit (ICU) mortality rates between patients managed by NPs and those managed by physicians. The aim of this study was to compare mortality rates between patients managed by an NP and those managed by physicians, both under the supervision of attending intensivists and to evaluate the potential impact of this care model on patient outcomes. This retrospective cohort study included patients aged 18 years or older who were admitted to the ICU between April 1, 2023, and March 31, 2024. Those managed by a single NP were classified into the NP group, and those managed by intensivists or residents were classified into the physician group. Due to potentially nonrandom allocation of patients, a weighted analysis based on propensity scores was applied. ICU mortality, ventilator days, and ICU length of stay were compared between the groups using weighted analyses. Among the 975 eligible patients, 109 and 866 were assigned to the NP and physician groups, respectively. Weighted analyses estimated the ICU mortality rate was 6.1% in the NP group and 7.2% in the physician group (risk difference: -0.01; 95% confidence interval [CI]: -0.06 to 0.03; risk ratio: 0.84; 95% CI: 0.39 to 1.83), the mean number of ventilator days was 1.6 in both groups (mean difference: 0.001; 95% CI: -1.09 to 1.09), and the mean ICU length of stay was 4.8 days in the NP group and 3.9 days in the physician group (mean difference: 0.91; 95% CI: -0.40 to 2.29). Our findings suggest that outcomes in the NP group were similar to those in the physician group. This specific model of NP-led care, delivered under supervision of attending intensivists, may be a feasible option to manage critically ill patients. However, this study was conducted in a single centre involving a single NP, and the wide CIs warrant cautious interpretation regarding the precision of the estimates.
Prescribing patterns for stress ulcer prophylaxis (SUP) may change over time as randomised controlled trials evaluate proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) for critically ill patients in the intensive care unit (ICU). The objective of this study was to compare site-specific, self-reported SUP prescribing and management practices before and after publication of the Re-Evaluating the Inhibition of Stress Erosions (REVISE) trial in participating ICUs. This was a preplanned study as part of the REVISE trial (NCT03374800), which compared intravenous pantoprazole with placebo in mechanically ventilated patients. The REVISE trial showed that intravenous pantoprazole reduced the risk of clinically important upper gastrointestinal bleeding and patient-important upper gastrointestinal bleeding, without a significant effect on mortality or other clinical outcomes. We conducted a survey of REVISE teams (one response from each pair of research coordinators and site physicians) in 68 participating sites to record their unit-based SUP practice patterns. Surveys were completed both before the site started enrolling patients and 10 months after the REVISE trial publication (response rate: 100%). A total of 58 sites (85.3%) and 65 sites (95.6%) included PPIs for SUP before and after the REVISE trial (P = 0.039). The most common indication for SUP discontinuation was extubation, followed by feed-related indications and ICU discharge during the pre-trial phase, which was similar after the trial. Order sets were used in 44 (64.7%) and 52 (76.5%) of sites in the pre-trial and post-trial phases, respectively (P = 0.022). In this survey of unit-based self-reported SUP practices before and after participation in a randomised trial, we found an increase in the use of PPIs and order sets, but strategies for discontinuation were unchanged.