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Background: During the COVID‐19 pandemic, intensive care units (ICUs) were under heavy pressure, with a significantly increased number of severely ill patients. Hospitals introduced restrictions, and families could not visit their ill and dying family members. Patients were cared for without privacy, and several died in shared patient rooms, leaving the intensive care nurse to protect the patient's need for loving care in a vulnerable situation at the end of life. Aim: This study aimed to investigate how piloting and watch over were revealed in end‐of‐life care for patients with COVID‐19 in intensive care COVID‐19. Study Design: A qualitative study was conducted with an abductive approach was conducted. Data were collected via semi‐structured interviews to cover the research area while allowing the informant to talk freely about the topic; 11 informants were interviewed. Results: The findings are presented based on four categories: The road to the decision, End‐of‐life care, Farewell of close family members and Closure. Each category and subcategory reveal how piloting and watch over were addressed in the end‐of‐life care of patients with COVID‐19 in the ICU during the pandemic. Overall findings indicated that workload and organization of care directly affect the quality of care given, the acceptance of privacy and the possibility of dignified end‐of‐life care. Conclusions: Workload directly affects the quality of care, risking dehumanization of the patient. Visiting restrictions hindered supporting family members through the various piloting phases. Visiting restrictions also forced the ICU nurses to take on the role of the relative in watching over the patient. Relevance to Clinical Practice: Collaboration with family members is essential for the intensive care nurse to be able to provide a person‐centred and dignified end‐of‐life care. [ABSTRACT FROM AUTHOR]

Urinary retention is a healthcare complication putting patients at risk of unnecessary suffering and harm. Orthopaedic patients are known to face an increased such risk, calling for evidence-based preoperative assessment and corresponding measures to prevent bladder problems. The aim of this study was to evaluate healthcare professionals' adherence to risk assessment guidelines for urinary retention in hip surgery patients. This was an observational study from January 2021 to April 2021 with a descriptive and comparative design, triangulating three data sources: (I) Medical records for 1382 hip surgery patients across 17 hospitals in Sweden were reviewed for preoperative risk assessments for urinary retention and voiding-related variables at discharge; (II) The patients completed a survey regarding postoperative lower urinary tract symptoms, and; (III) data were extracted from a national quality registry regarding type of surgery, preoperative physical status, and perioperative urinary complications. Group differences were analysed with Chi-square/Fisher's exact test, t -test, Wilcoxon rank-sum test, or Mann–Whitney U-test. Logistic regression was used to analyse variables associated with completed risk assessments for urinary retention. Of all study participants, 23.4% (n  = 323) had a preoperative documented risk assessment of urinary retention. Whether a risk assessment was performed was significantly associated with acute surgery [odds ratio (OR) 3.56, 95% confidence interval (CI) 2.48–5.12] and undergoing surgery at an academic hospital (OR 4.59, 95% CI 2.68–7.85). Acute patients were more often affected by urinary retention and had bladder issues and/or an indwelling catheter at discharge. More than every tenth patient (11. 9%, n  = 53) completing the survey experienced intensified bladder problems after their hip surgery. The study shows a lack of adherence to risk assessment for urinary retention according to evidence-based guidelines, which negatively affects quality of care and patient safety. [ABSTRACT FROM AUTHOR]

Background: The transfer from an intensive care unit (ICU) to a regular ward often causes confusion and stress for patients and family members. However, little is known about the patients' perspective on preparing for the transfer. Aim: The purpose of the study was to describe patients' experiences of preparing for transfer from an ICU to a ward. Study Design: Individual interviews with 14 former ICU patients from three urban hospitals in Stockholm, Sweden were conducted 3 months after hospital discharge. Qualitative content analysis was used to interpret the interview transcripts. Reporting followed the consolidated criteria for reporting qualitative research checklist. Results: The results showed that the three categories, the discharge decision, patient involvement, and practical preparations were central to the patients' experiences of preparing for the transition from the intensive care unit to the ward. The discharge decision was associated with a sense of relief, but also worry about what would happen on the ward. The patients felt that they were not involved in the decision about the discharge or the planning of their health care. To handle the situation, patients needed information about planned care and treatment. However, the information was often sparse, delivered from a clinician's perspective, and therefore not much help in preparing for transfer. Conclusions: ICU patients experienced that they were neither involved in the process of forthcoming care nor adequately prepared for the transfer to the ward. Relevant and comprehensible information and sufficient time to prepare were needed to reduce stress and promote efficient recovery. Relevance to Clinical Practice: The study suggests that current transfer strategies are not optimal, and a more person‐centred discharge procedure would be beneficial to support patients and family members in the transition from the ICU to the ward. [ABSTRACT FROM AUTHOR]

Aim: To describe healthcare workers' experiences of preconditions and patient safety risks in intensive care units during the COVID‐19 pandemic. Background: Healthcare workers' ability to adapt to changing conditions is crucial to promote patient safety. During the COVID‐19 pandemic, healthcare workers' capacity to maintain safe care was challenged and a more in‐depth understanding on frontline experiences of patient safety is needed. Design: A qualitative descriptive design. Methods: Individual interviews were conducted with 29 healthcare workers (nurses, physicians, nurse assistants and physiotherapists) from three Swedish hospitals directly involved in intensive care of COVID‐19 patients. Data were analysed with inductive content analysis. Reporting followed the COREQ checklist. Results: Three categories were identified. Hazardous changes in working conditions describes patient safety challenges associated with the extreme workload with high stress level. Imperative adaptations induced by changed preconditions for patient safety which include descriptions of safety risks following adaptations related to temporary intensive care facilities, handling shortage of medical equipment and deviations from routines. Safety risks triggered by reorganisation of care describe how the diluted skill‐mix and team disruptions exposed patients to safety risks, and that safety performance mostly relied on individual healthcare worker's responsibility. Conclusions: The study suggests that healthcare workers experienced an increase in patient safety risks during the COVID‐19 pandemic mainly because the extremely high workload, imperative adaptations, and reorganisation of care regarding skill‐mix and teamwork. Patient safety performance relied on the individuals' adaptability and responsibility rather than on system‐based safety. Relevance to Clinical Practice: This study provides insights on how healthcare workers' experiences can be used as a source of information for recognition of patient safety risks. To improve detection of safety risks during future crises, guidelines on how to approach safety from a system perspective must include healthcare workers' perceptions on safety risks. Patient and Public Contribution: None in the conceptualisation or design of the study. [ABSTRACT FROM AUTHOR]

Background: Management of intermittent claudication should include secondary prevention to reduce the risk of cardiocerebrovascular disease. Patient adherence to secondary prevention is a challenge. The aim of this study was to investigate whether a person-centred, nurse-led follow-up programme could improve adherence to medication compared with standard care. Methods: A non-blinded RCT was conducted at two vascular surgery centres in Sweden. Patients with intermittent claudication and scheduled for revascularization were randomized to the intervention or control (standard care) follow-up programme. The primary outcome, adherence to prescribed secondary preventive medication, was based on registry data on dispensed medication and selfreported intake of medication. Secondary outcomes were risk factors for cardiocerebrovascular disease according to the Framingham risk score. Results: Some 214 patients were randomized and analysed on an intention-to-treat basis. The mean proportion of days covered (PDC) at 1 year for lipid-modifying agents was 79 per cent in the intervention and 82 per cent in the control group, whereas it was 92 versus 91 per cent for antiplatelet and/or anticoagulant agents. The groups did not differ in mean PDC (lipid-modifying P= 0.464; antiplatelets and/or anticoagulants P=0.700) or in change in adherence over time. Self-reported adherence to prescribed medication was higher than registry-based adherence regardless of allocation or medication group (minimum P<0.001, maximum P=0.034). There was no difference in median Framingham risk score at 1 year between the groups. Conclusion: Compared with the standard follow-up programme, a person-centred, nurse-led follow-up programme did not improve adherence to secondary preventive medication. Adherence was overestimated when self-reported compared with registry-reported. [ABSTRACT FROM AUTHOR]

Background: Methods to identify patients at risk for incomplete physical recovery after intensive care unit (ICU) stay are lacking. Our aim was to develop a method for prediction of new-onset physical disability at ICU discharge.Methods: Multinational prospective cohort study in 10 general ICUs in Sweden, Denmark, and the Netherlands. Adult patients with an ICU stay ≥12 hours were eligible for inclusion. Sixteen candidate predictors were analyzed with logistic regression for associations with the primary outcome; new-onset physical disability 3 months post-ICU, defined as a ≥10 score reduction in the Barthel Index (BI) compared to baseline.Results: Of the 572 included patients, follow-up data are available on 78% of patients alive at follow-up. The incidence of new-onset physical disability was 19%. Univariable and multivariable modeling rendered one sole predictor for the outcome: physical status at ICU discharge, assessed with the five first items of the Chelsea critical care physical assessment tool (CPAx) (odds ratio 0.87, 95% confidence interval (CI) 0.81-0.93), a higher score indicating a lower risk, with an area under the receiver operating characteristics curve of 0.68 (95% CI 0.61-0.76). Negative predictive value for a low-risk group (CPAx score >18) was 0.88, and positive predictive value for a high-risk group (CPAx score ≤18) was 0.32.Conclusion: The ICU discharge assessment described in this study had a moderate AUC but may be useful to rule out patients unlikely to need physical interventions post-ICU. For high-risk patients, research to determine post-ICU risk factors for an incomplete rehabilitation is mandated. [ABSTRACT FROM AUTHOR]

Background: Critically ill COVID‐19 patients have a high reported incidence of thromboembolic complications and the optimal dose of thromboprophylaxis is not yet determined. The aim of this study was to investigate if 90‐day mortality differed between patients treated with intermediate‐ or high‐dose thromboprophylaxis. Method: In this retrospective study, all critically ill COVID‐19 patients admitted to intensive care from March 6th until July 15th, 2020, were eligible. Patients were categorized into groups according to daily dose of thromboprophylaxis. Dosing was based on local standardized recommendations, not on degree of critical illness or risk of thrombosis. Cox proportional hazards regression was used to estimate hazard ratios of death within 90 days from ICU admission. Multivariable models were adjusted for sex, age, body‐mass index, Simplified Acute Physiology Score III, invasive respiratory support, glucocorticoids, and dosing strategy of thromboprophylaxis. Results: A total of 165 patients were included; 92 intermediate‐ and 73 high‐dose thromboprophylaxis. Baseline characteristics did not differ between groups. The 90‐day mortality was 19.6% in patients with intermediate‐dose and 19.2% in patients with high‐dose thromboprophylaxis. Multivariable hazard ratio of death within 90 days was 0.74 (95% CI, 0.36–1.53) for the high‐dose group compared to intermediate‐dose group. Multivariable hazard ratio for thromboembolic events and bleedings within 28 days was 0.93 (95% CI 0.37–2.29) and 0.84 (95% CI 0.28–2.54) for high versus intermediate dose, respectively. Conclusions: A difference in 90‐day mortality between intermediate‐ and high‐dose thromboprophylaxis could neither be confirmed nor rejected due to a small sample size. [ABSTRACT FROM AUTHOR]

Background: Informal caregivers to intensive care unit (ICU) survivors may develop post‐intensive care syndrome family (PICS‐F), including depression, anxiety and post‐traumatic stress (PTS). Our primary aim was to investigate associations between caregiver burden in informal caregivers cohabiting with ICU survivors and patients' physical and psychological outcomes. Methods: A prospective, multicentre cohort study in four ICUs in Sweden. Adults cohabiting with ICU patients included in a previous study were eligible for inclusion. Three months post‐ICU, informal caregivers received questionnaires assessing caregiver burden, health‐related quality of life (HRQL) and symptoms of depression, anxiety and PTS. In parallel, patients reported their three‐month physical and psychological status via validated questionnaires. The primary outcome of this study was to compare caregiver burden in informal caregivers to patients with and without adverse physical and psychological outcomes 3 months post‐ICU. Secondary outcomes were correlations between caregiver burden and informal caregivers' mental HRQL. Results: Among 62 included informal caregivers, 55 (89%) responded to the follow‐up questionnaires. Caregiver burden was higher among informal caregivers to patients with an adverse outcome, compared to informal caregivers to patients without an adverse outcome, caregiver burden scale score mean (±standard deviation) 52 (11) and 41 (13) respectively (p = 0.003). There was strong negative correlation between caregiver burden and informal caregivers' mental HRQL (rs −0.74, p < 0.001). Conclusion: Informal caregivers to ICU survivors with adverse physical or psychological outcome experience a higher caregiver burden. A higher caregiver burden correlates with worse caregiver mental HRQL. ICU follow‐up programs should consider screening and follow‐up of informal caregivers for mental health problems. [ABSTRACT FROM AUTHOR]

Objectives: The full range of long‐term health consequences in intensive care unit (ICU) survivors with COVID‐19 is unclear. This study aims to investigate the role of ventilatory support for long‐term pulmonary impairment in critically ill patients and further to identify risk factors for prolonged radiological recovery. Methods: A prospective observational study from a single general hospital, including all with COVID‐19 admitted to ICU between March and August 2020, investigating the association between ventilatory support and the extent of residual parenchymal changes on chest computed tomography (CT) scan and measurement of lung volumes at follow‐up comparing high‐flow nasal oxygen (HFNO) or non‐invasive ventilation (NIV) with invasive ventilation. A semi‐quantitative score (CT involvement score) based on lobar involvement and a total score for all five lobes was used to estimate residual parenchymal changes. The association was calculated with logistic regression and adjusted for age, sex, smoking, and severity of illness. Results: Among the 187 eligible, 86 had a chest CT scan and 76 a pulmonary function test at the follow‐up with a median time of 6 months after ICU discharge. Residual lung changes were seen in 74%. The extent of pulmonary changes was similar regardless of ventilatory support, but patients with invasive ventilation had a lower total lung capacity 84% versus 92% of predicted (p < 0.001). Conclusions: The majority of ICU‐treated patients with COVID‐19 had residual lung changes at 6 months of follow‐up regardless of ventilator support or not, but the total lung capacity was lower in those treated with invasive ventilation. [ABSTRACT FROM AUTHOR]

Background: COVID‐19 can cause severe disease with need of treatment in the intensive care unit (ICU) for several weeks. Increased knowledge is needed about the long‐term consequences. Methods: This is a single‐center prospective follow‐up study of COVID‐19 patients admitted to the ICU for respiratory organ support between March and July 2020. Patients with invasive ventilation were compared with those with high‐flow nasal oxygen (HFNO) or non‐invasive ventilation (NIV) regarding functional outcome and health‐related qualify of life. The mean follow‐up time was 5 months after ICU discharge and included clinical history, three well‐validated questionnaires about health‐related quality of life and psychological health, pulmonary function test, 6‐minute walk test (6MWT) and work ability. Data were analyzed with multivariable general linear and logistic regression models with 95% confidence intervals. Results: Among 248 ICU patients, 200 patients survived. Of these, 113 patients came for follow‐up. Seventy patients (62%) had received invasive ventilation. Most patients reported impaired health‐related quality of life. Approximately one‐third suffered from post‐traumatic stress, anxiety and depression. Twenty‐six percent had reduced total lung capacity, 34% had reduced 6MWT and 50% worked fulltime. The outcomes were similar regardless of ventilatory support, but invasive ventilation was associated with more bodily pain (MSD −19, 95% CI: −32 to −5) and <80% total lung capacity (OR 4.1, 95% CI: 1.3‐16.5). Conclusion: Among survivors of COVID‐19 who required respiratory organ support, outcomes 5 months after discharge from ICU were largely similar among those requiring invasive compared to non‐invasive ventilation. [ABSTRACT FROM AUTHOR]

Author(s): Maria Cronhjort [sup.1], Johan Mårtensson [sup.2], Eva Joelsson-Alm [sup.1], Christer Svensen [sup.1] Author Affiliations: (1) grid.4714.6, 0000000419370626, Department of Clinical Science and Education, Karolinska Institutet, , Sjukhusbacken 10, 11883, [...]

Objectives The objective of this study was to explore firefighters’ and police officers’ experiences of responding to out-of- hospital cardiac arrest (OHCA) in a dual dispatch programme. Design A qualitative interview study with semi-structured, open-ended questions where critical incident technique (CIT) was used to collect recalled cardiac arrest situations from the participants’ narratives. The interviews where transcribed verbatim and analysed with inductive content analysis. Setting The County of Stockholm, Sweden. Participants Police officers (n=10) and firefighters (n=12) participating in a dual dispatch programme with emergency medical services in case of suspected OHCA of cardiac or non-cardiac origin. Results Analysis of 60 critical incidents was performed resulting in three consecutive time sequences (preparedness, managing the scene and the aftermath) with related categories, where first responders described the complexity of the cardiac arrest situation. Detailed information about the case and the location was crucial for the preparedness, and information deficits created stress, frustration and incorrect perceptions about the victim. The technical challenges of performing cardiopulmonary resuscitation and managing the airway was prominent and the need of regular team training and education in first aid was highlighted. Conclusions Participating in dual dispatch in case of suspected OHCA was described as a complex technical and emotional process by first responders. Providing case discussions and opportunities to give, and receive feedback about the case is a main task for the leadership in the organisations to diminish stress among personnel and to improve future OHCA missions. [ABSTRACT FROM AUTHOR]

Background: Urinary retention is a common complication following hospital care, which can result in overdistension of the bladder and, at worst, chronic bladder damage and persistent micturition difficulties. Objectives: The purpose of this study was to explore patients’ experiences of micturition problems after bladder distension and their effects on the patients’ everyday lives. Methods:The Swedish Patient Insurance LOF was used to identify patients from January 2007 to June 2010 who have reported micturition problems after hospital care and have had their injuries classified as avoidable bladder damage due to overdistension. Narrative interviews were conducted with 20 volunteers and analyzed by qualitative content analysis. Results: The micturition problems affected everyday life through constraints (dependence on disposables and access to toilets, clothing restrictions, limitations on social life and career), suffering (pain, infections, impaired sex life, leakage), and concerns for the future (fear of worsening symptoms and fear of losing control with age). Aspects related to having been harmed by the healthcare system were the harm could have been avoided (lack of knowledge, insufficient routines, mistrust), obstacles to overcome when reporting an injury (difficulties in obtaining knowledge about the possibility of reporting an injury, ambivalence toward reporting their healthcare providers), and a wish to improve care (raise awareness, prevent harm to others). Discussion: Bladder distension is a healthcare-related injury that can cause suffering and practical, emotional, and psychosocial problems with a great impact on the life of the person affected and anxiety for the future. The healthcare system must, therefore, raise awareness and improve preventive routines. [ABSTRACT FROM AUTHOR]

Objective. The aim of this study was to explore whether close preoperative ultrasound monitoring starting in the emergency room (ER) could prevent postoperative bladder distension among acute orthopaedic patients. Material and methods. A randomized controlled trial was conducted at a 650-bed level-2 centre in Sweden. Inclusion criteria were admittance via ER to an orthopaedic ward for acute surgery. Bladder volumes were measured with a portable ultrasound scanner (Bladderscan BVI 3000). In the intervention group, all patients were scanned in the ER and then regularly at the ward at predefined times until surgery. In the control group, no regular scanning was performed before surgery. During surgery, the same procedure was performed for both groups: bladder scanning immediately after arrival to the recovery room and continuous postoperative scanning until voiding. The primary outcome was postoperative bladder distension, defined as a bladder volume ≥500 ml. Secondary outcomes were postoperative urinary tract infection and hospital length of stay. Results. A total of 281 patients completed the study, 141 in the intervention group and 140 in the control group. Postoperative bladder distension was significantly higher in the control group (27.1% vs 17.0%; p == 0.045, 95% confidence interval 4.9-19.8) in the intention-to-treat, per-protocol and as-treated analyses. No statistical difference was found between the intervention group and the control group regarding the secondary outcomes. Conclusions. Frequent bladder monitoring starting in the ER can reduce postoperative bladder distension among acute orthopaedic patients. A preoperative bladder monitoring protocol should be implemented early in the ER for all patients admitted for acute orthopaedic procedures. [ABSTRACT FROM AUTHOR]

Objective. Postoperative urinary retention and bladder distension are frequent complications of surgery. The aim of this study was to determine the incidence of perioperative bladder distension in a surgical setting and to identify predisposing factors among patients undergoing common general and orthopaedic procedures. Material and methods. This was a prospective observational study of 147 adult patients admitted to orthopaedic and surgical departments. Bladder volumes were measured with an ultrasound scanner on three occasions: after emptying the bladder before being transported to the operating theatre, and then immediately before and after surgery. Results. Thirty-three patients (22%) developed bladder distension (>500 ml), eight preoperatively and 25 postoperatively. A total of 21 patients (14%) had a bladder volume >300 ml immediately before surgery. Orthopaedic patients were more likely to develop preoperative bladder distension than surgical patients and had significantly higher postvoid residual volumes. In the binary logistic regression analysis age, gender and time of anaesthesia could not predict bladder distension. Patients undergoing orthopaedic surgical procedures, however, were prone to bladder distension (odds ratio 6.87, 95% confidence interval 1.76 to 26.79, p=0.006). Conclusions. This study shows that orthopaedic surgical patients are more prone to bladder distension perioperatively. The conventional method of encouraging patients to void at the ward before being transported to the operating theatre does not necessarily mean an empty bladder at the start of the operation. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodsResultsConclusions\nIMPLICATIONS FOR REHABILITATIONTo describe experiences of the ward nurse in relation to extended physiotherapy and mobilising of post-ICU patients.Individual semi-structured interviews were conducted with 17 registered nurses working on surgical wards in a Swedish regional hospital. Qualitative content analysis was used to analyse the data. The study was reported according to the consolidated criteria for reporting qualitative research (COREQ).The study findings are presented in three categories: challenges to mobilising post-ICU patients, shared responsibility facilitates mobilisation, and extended physiotherapy is beneficial for patients’ wellbeing. Nurses stated that they lacked knowledge and skills to perform the safe mobilisation of post-ICU patients due to their complex medical history and needs. Collaboration with physiotherapists was perceived to facilitate mobilisation and to be beneficial for patients’ wellbeing outcome.The study indicates that post-ICU patients are at risk of remaining immobilised because ward nurses find mobilisation too complex to conduct without support from physiotherapists. Shared responsibility through multi-professional teamwork regarding patient rehabilitation is perceived as contributing the knowledge required to achieve safe mobilisation that enhances autonomy and physical ability in post-ICU patients.Level of mobilisation is commonly reduced when patients are transferred from ICU to ward.Collaboration between physiotherapists and nurses can facilitate a first mobilisation in a safe way and subsequently be beneficial for patients’ wellbeing.There is a need for a more robust healthcare chain which promotes continued rehabilitation and reduces the risk of physical decline for the individual patient after being transferred from ICU to ward. [ABSTRACT FROM AUTHOR]

Aim(s) Design Methods Results Conclusion Implications for the Profession and/or Patient Care Impact Reporting Method To explore first‐line managers' experience of guideline implementation in orthopaedic care during the COVID‐19 pandemic.A descriptive, qualitative study.Semi‐structured interviews with 30 first‐line nursing and rehabilitation managers in orthopaedic healthcare at university, regional and local hospitals. The interviews were analysed by thematic analysis.First‐line managers described the implementation of guidelines related to the pandemic as different from everyday knowledge translation, with a swifter uptake and time freed from routine meetings in order to support staff in adoption and adherence. The urgent need to address the crisis facilitated guideline implementation, even though there were specific pandemic‐related barriers such as staffing and communication issues. An overarching theme, Hanging on to guidelines for dear life, is substantiated by three themes: Adapting to facilitate change, Anchoring safety through guidelines and Embracing COVID guidelines.A health crisis such as the COVID‐19 pandemic can generate enabling elements for guideline implementation in healthcare, despite prevailing or new hindering components. The experience of guideline implementation during the COVID‐19 pandemic can improve understanding of context aspects that can benefit organizations in everyday translation of evidence into practice.Recognizing what enabled guideline implementation in a health crisis can help first‐line managers to identify local enabling context elements and processes. This can facilitate future guideline implementation.During the COVID‐19 pandemic, the healthcare context and staff's motivation for guideline recognition and adoption changed. Resources and ways to bridge barriers in guideline implementation emerged, although specific challenges arose. Nursing managers can draw on experiences from the COVID‐19 pandemic to support implementation of new evidence‐based practices in the future.This study adheres to the EQUATOR guidelines by using Standards for Reporting Qualitative Research (SRQR).No Patient or Public Contribution. [ABSTRACT FROM AUTHOR]