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Background: Care partners are individuals chosen by a person with an illness to support their care during hospitalization. Patients with persistent critical illness have longer than average critical care admission and often other conditions including dysphagia, communication vulnerability, severe physical deconditioning, the need for an artificial airway, and difficulty weaning from invasive mechanical ventilation. Family presence has been identified as important for patients experiencing persistent critical illness in specialized weaning centers. Despite this, the role of care partners in clinical settings for patients with persistent critical illness has not been fully characterized, particularly from the perspectives of patients, care partners, and health care providers. The aim of this study was to gain insights into the roles of care partners during persistent critical illness from the perspectives of patients, care partners, and health care providers. Methods: We used qualitative descriptive methodology including semi-structured interviews and content analysis. Interviews were audio recorded and transcribed verbatim. Included participants (n = 30) were patient survivors (n = 7), care partners of patient survivors (n = 9), and professionally diverse health care providers (n = 14) of adult patients with persistent critical illness from two specialized units in one community academic hospital in Toronto, Canada. Results: Participants across all groups described care partner roles that included physical, mental health, cognitive, social, and spiritual support of the patient, including the perceived role of safeguarding the multiple dimensions of care for the patient who is experiencing persistent critical care in specialized care settings. Discussion: The results of this study are being used to co-design, implement, and evaluate a sustainable care partner program that is acceptable, appropriate, and feasible to implement in clinical settings where the care of patients with persistent critical illness occurs. Reporting method: Consolidated criteria for reporting qualitative studies (COREQ). [ABSTRACT FROM AUTHOR]

Competing Interests: The authors declare no conflict of interest.

Competing Interests: The authors declare no conflict of interest.

Competing Interests: The authors declare no conflicts of interests.

Background: Patients with persistent critical illness experience prolonged multi-system morbidity, functional impairments, and chronic conditions. As a result, these patients have prolonged intensive care unit admissions. If discharged, they return home with long-term medical dependencies. Care partners take on a variety of physical, mental health, cognitive, and social roles to support the provision of care for these patients. There is limited evidence, however, of the impact of being a care partner for this patient population during hospitalization., Methods: A qualitative descriptive study was conducted to explore the impact care provision on care partners for patients experiencing persistent critical illness. Patients who have or have had persistent critical illness and care partners were recruited from two inpatient units in a single community academic hospital in Toronto, Canada to participate in semi-structured interviews. Data was analyzed using a team-based inductive content analysis., Results: Seven (43.8%) participants were patient survivors, and nine (56.3%) were care partners. Patients and care partners reported physical, socio-emotional, and social stress as impacts of care provision during persistent critical illness hospitalization. Care partners identified several protective strategies that they used to mitigate the impacts of care provision on them such as seeking external mental health support and boundary setting. Features of formalized and care partner programs were also identified and suggest that these programs can be protective of care partner values, mitigate feelings of helplessness and stress, and may improve relationships between the family members who are in the care partner role and the healthcare team., Conclusions: This study identified physical, socio-emotional, and social stress related impacts of care provision on care partners of patients with persistent critical illness during hospitalization. Additionally, this study identified protective factors initiated by care partners to mitigate the reported stresses of the role, as well as protective features of a care partner program. The results provide a better understanding supportive features of care partner programs that are specific to the experiences and needs of persistent critical illness and add to the growing body of evidence about how to provide equitable access to care during and post hospitalization., (© 2024. The Author(s).)

Objectives: Critically ill adults requiring artificial airways experience profound communication deficits. Studies of interventions supporting communication report disparate outcomes, creating subsequent challenges in the interpretation of their effectiveness. Therefore, we aimed to develop international consensus for a communication core outcome set (Comm-COS) for future trials of communication interventions in this population., Design: 1) Systematic review, 2) patient/family interviews, 3) two-round modified Delphi, and 4) virtual consensus meetings with a final voting round. A multidisciplinary expert steering committee oversaw all stages., Setting: Interviews and consensus meetings were conducted via videoconferencing. Digital methods were used for Delphi and final Comm-COS voting., Subjects: Three stakeholder groups: 1) patient and family members with lived experience within 3 years, 2) clinicians with experience working in critical care, and 3) researchers publishing in the field., Intervention: None., Measurements and Main Results: We identified 59 outcomes via our systematic review, 3 unique outcomes from qualitative interviews, and 2 outcomes from our steering committee. Following item reduction, 32 outcomes were presented in Delphi round 1; 134 participants voted; 15 patient/family (11%), 91 clinicians (68%), and 28 researchers (21%). Nine additional outcomes were generated and added to round 2; 106 (81%) participants voted. Following completion of the consensus processes, the Comm-COS includes seven outcomes: 1) changes in emotions and wellbeing associated with ability to communicate, 2) physical impact of communication aid use, 3) time to functional communication, 4) ability to communicate healthcare needs (comfort/care/safety/decisions), 5) conversation agency, 6) ability to establish a communication connection to develop and maintain relationships, and 7) acceptability of the communication intervention., Conclusions: This is the first COS to specifically focus on communication for critically ill adults. Limitations for operationalization include selection of measures to use with these outcomes. Identification of suitable measures and adoption of the Comm-COS in future trials will help establish effective interventions to ameliorate the highly prevalent and negative experience of communicative incapacity., Competing Interests: Dr. Freeman-Sanderson received support for article research from an internal university seed grant from Faculty of Health, University of Technology Sydney (UTS). Dr. Brodsky’s institution received funding from the National Institutes of Health and the Food and Drug Administration; he received funding from MedBridge and Phagenesis. Dr. Happ received funding from internal research funds, the Healthy State Alliance Momentum grant; she disclosed that she holds the copyright to the Study of Patient-Nurse Effectiveness with Assisted Communication Strategies (SPEACS-2) online communication training program. Sullivan’s institution received funding from UTS. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.)

Background: Health care costs attributed to COPD have been estimated at $4.7 trillion globally in the next 30 years. With the global burden of COPD rising, identification of interventions that might lead to health care cost savings is an imperative. Although many studies report the effect of COPD self-management interventions on subject outcomes and health care utilization, few data describe their effect on health care costs., Methods: Using data linkage and established case-costing methods with provincial Canadian health databases, we established public health care costs (acute and community) for 12 months following randomization for the 462 participants enrolled in our randomized controlled trial of the Program of Integrated Care for Patients with COPD and Multiple Comorbidities., Results: Total median (interquartile range) in-hospital costs in the 12 months follow-up for all (intervention and control) 462 trial participants were CAD $4,769 ($417-16,834) (equivalent to US $3,566 [$312-12,588]). Total costs incurred in the community were higher at CAD $8,011 ($4,749-13,831) (equivalent to US $5,990 [$3,551-10,342]). Controlling for sex, income quintile, Johns Hopkins Aggregated Diagnosis Groups score, and living in an urban locality, we found lower community health care costs but no differences in acute care costs for participants receiving our multicomponent COPD exacerbation prevention management intervention compared to usual care., Conclusions: Controlling for important confounders, we found lower public community health care costs but no difference in acute health care costs with our multicomponent COPD exacerbation prevention management intervention compared to usual care. Community health care costs were almost double those incurred compared to acute health care costs. Given this finding, although most COPD exacerbation management interventions generally focus on reducing the use of acute care, interventions that enable health care cost savings in the community require further exploration., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Competing Interests: The authors declare no conflict of interest.

Competing Interests: The author declares no conflicts of interest.

Patients and families in critical care have a high likelihood of previous and re-experienced trauma. Unaddressed, physical, and psychological impacts of these traumas can worsen outcomes for patients and families. A trauma-informed care approach has been proposed for critical care; however, training programs do not include relational competencies or de-escalation techniques, risking the re-traumatization of patients and families in critical care and negatively impacting clinicians. This article describes a strategy that can be adopted by critical care teams towards the creation of a trauma-informed critical care unit including the use of a framework for relational training. Principles of relationship management and de-escalation are discussed with the use of a fictional exemplar scenario. Key messages include a call to action for relational training for care teams to enhance skilled relational engagement of patients and families. This article also highlights the foundational importance of policies supporting a trauma-informed approach in critical care., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: The authors declare no conflicts of interest.

Aim: To explore clinician-perceived barriers to and facilitators for the provision of actionable processes of care important for patients with persistent or chronic critical illness., Design: Qualitative descriptive interview study., Methods: Secondary analysis of semi-structured telephone interviews (December 2018 - February 2019) with professionally diverse clinicians working with adults experiencing persistent or chronic critical illness in Canadian intensive care units. We used deductive content analysis informed by the Social-Ecological Model., Results: We recruited 31 participants from intensive care units across nine Canadian provinces. Reported intrapersonal level barriers to the provision of actionable processes of care included lack of training, negative emotions and challenges prioritizing these patients. Facilitators included establishment of positive relations and trust with patients and family. Interpersonal barriers included communication difficulties, limited access to physicians and conflict. Facilitators included communication support, time spent with the patient/family and conflict management. Institutional barriers comprised inappropriate care processes, inadequate resources and disruptive environmental conditions. Facilitators were regular team rounds, appropriate staffing and employment of a primary care (nurse and/or physician) model. Community-level barriers included inappropriate care location and insufficient transition support. Facilitators were accessed to alternate care sites/teams and to formalized transition support. Public policy-level barriers included inadequacy of formal education programs for the care of these patients; knowledge implementation for patient management was identified as a facilitator., Conclusion: Our results highlighted multilevel barriers and facilitators to the delivery of actionable processes important for quality care for patient/family experiencing persistent or chronic critical illness., Impact: Using the Social-Ecological Model, the results of this study provide intra and interpersonal, institutional, community and policy-level barriers to address and facilitators to harness to improve the care of patients/family experiencing persistent or chronic critical illness., Reporting Method: Consolidated criteria for reporting qualitative studies., Patient or Public Contribution: No patient or public contribution., (© 2023 John Wiley & Sons Ltd.)

Background: Research co-design is recommended to reduce misalignment between researcher and end-user needs and priorities for healthcare innovation. Engagement of intensive care unit patients, clinicians, and other stakeholders in co-design has historically relied upon face-to-face meetings. Here, we report on our co-design processes for the development of a bundled intensive care unit patient communication intervention that used exclusively virtual meeting methods in response to COVID-19 pandemic social distancing restrictions., Methods: We conducted a series of virtual co-design sessions with a committee of stakeholder participants recruited from a medical-surgical intensive care unit of a community teaching hospital in Toronto, Canada. Published recommendations for co-design methods were used with exclusively virtual adaptations to improve ease of stakeholder participation as well as the quality and consistency of co-design project set-up, facilitation, and evaluation. Virtual adaptations included the use of email for distributing information, videos, and electronic evaluations as well as the use of a videoconferencing platform for synchronous meetings. We used a flexible meeting plan including asynchronous virtual methods to reduce attendance barriers for time-constrained participants., Results: Co-design participants included a patient and a family member (n = 2) and professionally diverse healthcare providers (n = 9), plus a facilitator. Overall, participants were engaged and reported a positive experience with the virtually adapted co-design process. Reported benefits included incorporation of diverse viewpoints in the communication intervention design and implementation plan. Challenges related to lack of hands-on time during development of the co-designed intervention and participant availability to meet regularly albeit virtually., Conclusions: This report describes the methods, benefits, and challenges of adapting in-person co-design methods to a virtual environment to produce a bundled communication intervention for use in the adult intensive care unit during the COVID-19 pandemic. Adapting recommended co-design methods to a virtual environment can provide further opportunities for stakeholder participation in intervention design., (© 2023. The Author(s).)

Background: Although bundled communication interventions are recommended to address communication barriers for patients with an advanced airway in the intensive care unit (ICU) such interventions have not been evaluated in pandemic conditions., Aim: To evaluate the acceptability, appropriateness, and feasibility of a co-designed bundled intervention to support communication with adult patients with an advanced airway in ICU in pandemic conditions., Study Design: Prospective, convergent mixed method design in a single centre medical-surgical ICU in Toronto, Canada between September 2021-March 2022. After the use of the co-designed bundled communication intervention quantitative data were collected from health care providers using validated acceptability, appropriateness, and feasibility measures and analysed using descriptive statistics. Qualitative data were collected from providers, patients and families using semi-structured interviews and analysed using content analysis applying the theoretical framework of acceptability. Joint table analysis enabled the integration of the two data sets., Results: A total of 64 (41.3%) HCPs responded to the survey: 54 (84.4%) rated the intervention acceptable; 55 (85.9%) appropriate; and 49 (76.6%) feasible for use in this context. Qualitative data (23 interviews: 13 healthcare providers, 6 families and 4 patients) and the joint table analysis extended the understanding that intervention acceptability was related to positive affective attitudes and reduced communication frustration. Appropriateness and feasibility were promoted through intervention alignment with values, ability to personalize tools, and ease of access. Recommendations to improve the acceptability included adaptation for immobilized and/or restrained patients, additional education, and integration into existing workflows., Conclusions: This mixed method evaluation of a co-designed bundled intervention to support patient communication in the ICU during pandemic conditions demonstrated high rated and described acceptability, appropriateness, and feasibility by participants., Relevance to Clinical Practice: A co-designed communication intervention demonstrating stakeholder acceptability, appropriateness, and feasibility can be implemented into clinical practice in pandemic and other infection prevention and control contexts., (© 2022 British Association of Critical Care Nurses.)

Purpose: Few quality improvement tools specific to patients with persistent or chronic critical illness exist to aid delivery of high-quality care. Using experience-based co-design methods, we sought consensus from key stakeholders on the most important actionable processes of care for inclusion in a quality improvement checklist., Methods: Item generation methods: systematic review, semi-structured interviews (ICU survivors and family) members, touchpoint video creation, and semi-structured interviews (ICU clinicians). Consensus methods: modified online Delphi and a virtual meeting using nominal group technique methods., Results: We enrolled 138 ICU interprofessional team, patients, and family members. We obtained consensus on a quality improvement checklist comprising 11 core domains: patient and family involvement in decision-making; patient communication; physical comfort and complication prevention; promoting self-care and normalcy; ventilator weaning; physical therapy; swallowing; pharmacotherapy; psychological issues; delirium; and appropriate referrals. An additional 27 actionable processes are contained within 6 core domains that provide more specific direction on the actionable process to be targeted., Conclusions: Using a highly collaborative and methodologically rigorous process, we generated a quality improvement checklist of actionable processes to improve patient and family-centred care considered important by key stakeholders. Future research is needed to understand optimal implementation strategies and impact on outcomes and experience., Competing Interests: Declaration of Competing Interest The authors have no declarations of interest to declare., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Aim: To use positive deviance to identify actionable processes of care that may improve outcomes and experience from the perspectives of prolonged intensive care unit (ICU) stay survivors and family members., Design: Prospective qualitative interview study in two geographically distant settings: Canada (2018/19) and the United Kingdom (2019/20)., Methods: Patient and family participant inclusion criteria comprised: aged over 18 years, ICU stay in last 2 years of over 7 days, able to recall ICU stay and provided informed consent. We conducted semi-structured in-person or telephone interviews. Data were analysed using a positive deviance approach., Results: We recruited 29 participants (15 Canadian; 14 UK). Of these, 11 were survivors of prolonged ICU stay and 18 family members. We identified 22 actionable processes (16 common to Canadian and UK participants, 4 Canadian only and 2 UK only). We grouped processes under three themes: physical and functional recovery (nine processes), patient psychological well-being (seven processes) and family relations (six processes). Most commonly identified physical/functional processes were regular physiotherapy, and fundamental hygiene and elimination care. For patient psychological well-being: normalizing the environment and routines, and alleviating boredom and loneliness. For family relations: proactive communication, flexible family visiting and presence with facilities for family. Our positive deviance analysis approach revealed that incorporation of these actionable processes into clinical practice was the exception as opposed to the norm perceived driven by individual acts of kindness and empathy as opposed to standardized processes., Conclusion: Actionable processes of care important to prolonged ICU stay survivors and family members differ from those frequently used in ICU quality improvement (QI) tools., Impact: Our study emphasizes the need to develop QI tools that standardize delivery of actionable processes important to patients and families experiencing a prolonged ICU stay. As the largest healthcare professional group, nurses can play an essential role in leading this., (wileyonlinelibrary.com/journal/jan.)

Background: Quantification of long-term survival, health care utilization, and costs of prolonged ventilator dependence informs patient/family decision-making, health care policy, and understanding of specialized weaning centers (SWCs) as alternate care models. Our objective was to compare survival trajectory, health care utilization, and costs of SWC survivors with a matched cohort of ≥ 21-d-stay ICU patients., Methods: This was a retrospective longitudinal (12 y) case-control study linking to health administrative databases with matching on age, sex, Charlson comorbidity index, income quintiles, and days in ICU and hospital in preceding 12 months., Results: We matched 201 SWC subjects to 201 prolonged ICU survivors (402-subject cohort); 42% had a Charlson score of > 4. Risk of death at 12 months was lower in SWC subjects (hazard ratio [HR] 0.70 [95% CI 0.54-0.91]) adjusting for length of hospital admission (HR 1.02 [95% CI 1.00-1.04]) and number of care location transfers (HR 0.84 [95% CI 0.75-0.93]). By follow-up end, more SWC subjects died, 149 (73%) versus 127 (62%). We found no difference in discharge to home. At 12 months, acute health care utilization was comparable for the entire cohort, except hospital readmission rates (median interquartile range [IQR] 2 [1-3) vs 1 [1-2] d). Median (IQR) cost 12 months after unit discharge was CAD $68,165 ($19,894-$153,475). 12-month costs were higher in the SWC survivors (CAD $82,874 [$29,942-$224,965] vs CAD $55,574 [$6,572-$128,962], P < .001). SWC survivors had higher community health care utilization. Regression modeling demonstrated cost was associated with stay and care transfers but not SWC admission. Over 12-y follow-up, health care utilization and costs were higher in SWC survivors., Conclusions: SWC admission may confer some medium-term survival advantage; however, this may be influenced by selection bias associated with admission criteria., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2022 by Daedalus Enterprises.)

Introduction: Patients requiring invasive mechanical ventilation via an artificial airway experience sudden voicelessness placing them at risk for adverse outcomes and increasing provider workload. Infection control precautions during the COVID-19 pandemic, including the use of personal protective equipment (eg, gloves, masks, etc), patient isolation, and visitor restrictions may exacerbate communication difficulty. The objective of this study is to evaluate the acceptability of a codesigned communication intervention for use in the adult intensive care unit when infection control precautions such as those used during COVID-19 are required., Methods and Analysis: This three-phased, prospective study will take place in a medical surgical ICU in a community teaching hospital in Toronto. Participants will include ICU healthcare providers, adult patients and their family members. Qualitative interviews (target n: 20-25) will explore participant perceptions of the barriers to and facilitators for supporting patient communication in the adult ICU in the context of COVID-19 and infection control precautions (phase 1). Using principles of codesign, a stakeholder advisory council of 8-10 participants will iteratively produce an intervention (phase 2). The codesigned intervention will then be implemented and undergo a mixed method acceptability evaluation in the study setting (phase 3). Acceptability, feasibility and appropriateness will be evaluated using validated measures (target n: 60-65). Follow-up semistructured interviews will be analysed using the theoretical framework of acceptability (TFA). The primary outcomes of this study will be acceptability ratings and descriptions of a codesigned COmmunication intervention for use during and beyond the COVID-19 PandEmic., Ethics and Dissemination: The study protocol has been reviewed, and ethics approval was obtained from the Michael Garron Hospital. Results will be made available to healthcare providers in the study setting throughout the study and through publications and conference presentations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background : Pain is a significant problem in adults living with advanced liver disease, having limited guidance available for its clinical management. While pain is considered a multidimensional experience, there have been limited reviews of the pain literature in advanced liver disease conducted with a multidimensional framework. Aims: The goal of this scoping review was to identify and map the multidimensional domains of pain in adults with advanced liver disease using the biopsychosocial model. Methods: We used Arksey and O'Malley's scoping framework. A search was conducted in MEDLINE, Embase, AMED, and CINAHL databases and the gray literature using specific eligibility criteria (1990-2019). Citation selection and data extraction were performed by two independent reviewers and in duplicate. Results: Of the 43 studies that met inclusion criteria, 51% were from North America and 93% utilized quantitative methods. The combined studies reported on 168,110 participants with ages ranging between 23 to 87 years. Only 9% reported an objective scoring system for liver disease severity. Few studies reported pain classification (9%) and intensity (16%). Pain prevalence ranged between 18% and 100%, with pain locations including joint, abdomen, back, head/neck, and upper/lower extremities. We identified and mapped 115 pain factors to the biopsychosocial model: physical (81%), psychological (65%), and sociocultural (5%). Only 9% measured pain using validated multidimensional tools. Pharmacological intervention (92%) prevailed among pain treatments. Conclusions: Pain is not well understood in patients with advanced liver disease, having limited multidimensional pain assessment and treatment approaches. There is a need to systematically examine the multidimensional nature of pain in this population., Competing Interests: Franklin Gorospe does not have any conflicts of interest. Laura Istanboulian does not have any conflicts of interest. Dr. Martine Puts does not have any conflicts of interest. Dr. David Wong does not have any conflicts of interest. Elizabeth Lee does not have any conflicts of interest. Dr. Craig Dale does not have any conflicts of interest., (© 2020 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Objectives: Family caregivers of patients requiring prolonged mechanical ventilation may experience physical and psychological morbidity associated with a protracted intensive care unit experience. Our aim was to explore potentially modifiable support needs and care processes of importance to family caregivers of patients requiring prolonged mechanical ventilation and transition from the intensive care unit to a specialised weaning centre., Research Methodology/design: A longitudinal qualitative descriptive interview study. Data was analysed using directed content analysis., Setting: A 6-bed specialised weaning centre in Toronto, Canada., Findings: Eighteen family caregivers completed interviews at weaning centre admission (100%), and at two-weeks (40%) and three-months after discharge (22%) contributing 29 interviews. Caregivers were primarily women (61%) and spouses (50%). Caregivers perceived inadequate informational, emotional, training, and appraisal support by health care providers limiting understanding of prolonged ventilation, participation in care and decision-making, and readiness for weaning centre transition. Participants reported long-term physical and psychological health changes including alterations to sleep, energy, nutrition and body weight., Conclusions: Deficits in informational, emotional, training, and appraisal support of family caregivers of prolonged mechanical ventilation patients may increase caregiver burden and contribute to poor health outcomes. Strategies for providing support and maintaining family caregiver health-related quality of life are needed., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: To identify barriers and facilitators for the use of augmentative and alternative communication (AAC) and voice restorative strategies for adult patients with an advanced airway in the intensive care unit (ICU)., Materials and Methods: Scoping review searching five databases between 1990 and 2019. We screened 13, 167 citations and included all study types reporting barriers and/or facilitators to using communication strategies in an ICU setting. Two authors independently extracted and coded reported barriers and facilitators to the Theoretical Domains Framework (TDF) domains., Results: Of the 44 studies meeting inclusion criteria 18 (44%) used qualitative, 18 (44%) used quantitative, and 8 (18%) used mixed methods. In total, 39 unique barriers and 46 unique facilitators were identified and coded to the domains of the TDF. Barriers were most frequently coded to the Skills, Environmental Context and Resources, and Emotion domains. Facilitators were most frequently coded to Reinforcement, Environmental Context and Resources, and Social and Professional Roles/Identity domains. Thematic synthesis produced four potentially modifiable factors: context, emotional support, training, and decisional algorithms., Conclusions: Identified barriers (skills, environment, resources, emotions) and facilitators (reinforcement, resources, roles) to ICU communication strategy use in the literature may be modified through formal training and role support., Competing Interests: Declaration of Competing Interest The authors declare no competing interests other than authorship of an included study (Rose et al., 2018)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Despite end-stage COPD, she is able to make a graceful final exit on her own terms.

Background: Mechanically ventilated patients in the intensive care unit (ICU) experience profound communication impairment, placing them at risk for poor physical and psychological outcomes. Patient communication strategies such as augmentative and alternative communication (AAC) and voice restorative devices are recommended to facilitate communication. These strategies, however, are inconsistently adopted in ICU practice signaling utilization barriers. Our objective is to map and synthesize the current evidence-base for stakeholder-reported barriers and facilitators to patient communication strategy utilization for adults with an advanced airway in the ICU., Methods and Analysis: We will use Arskey and O'Malley's recommended methods to conduct a scoping review using a rapid review framework to streamline the process. A single reviewer will conduct a search and an initial screen of titles and abstracts from five electronic databases (MEDLINE, EMBASE, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature [CINAHL], and PsychInfo) from 1990 to present to identify English language peer-reviewed studies. Subsequently, two reviewers will independently screen a shorter list of studies for inclusion. We will also search the reference lists of eligible studies. Two reviewers will independently extract study characteristics, communication strategy, and stakeholder reported barriers and facilitators. We will code and categorize the extracted barriers and facilitators according to the Theoretical Domains Framework (TDF), an integrative framework of behavior change., Discussion: To our knowledge, this will be the first scoping review to map and synthesize reported barriers and facilitators to communication strategy utilization in the adult ICU using a theoretical framework. The results of this scoping review will help to identify trends and gaps in the current evidence-base and support recommendations for improving patient-centered practice, policy, and research related to successfully establishing ICU patient communication.

Introduction: Pain is highly prevalent in the adult population diagnosed with liver disease. Those progressing to advanced liver disease often experience persistent pain and poor pain relief. There is presently limited guidance for the management of pain and associated symptoms in this population. The current literature lacks attention on how physical, psychological and social domains of liver disease modulate the pain experience. In this paper, we outline our scoping review protocol to systematically review the literature from academic bibliographic databases and grey sources to identify and map the biopsychosocial factors associated with pain in adults with advanced liver disease., Methods and Analysis: Arksey and O'Malley's methodology, and Tricco et al 's Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, will guide the process for this scoping review. The literature search will include electronic and hand-searching methods using scholarly and grey sources. Scholarly databases include Medline, Embase, Allied and Complementary Medicine and Cumulative Index to Nursing and Allied Health Literature. Grey databases will focus on research studies not captured in the scholarly databases including those by government agencies and professional organisations. Two members of the research team will independently screen the resulting publications following specific inclusion and exclusion criteria. Quality appraisal of the included research studies will employ the use of the Mixed Methods Appraisal Tool version 2018. Data collection and extraction of study characteristics will use a data extraction tool developed iteratively by the research team. Analysis of the factors associated with pain outcomes will be mapped and described according to the domains of the biopsychosocial model of pain., Ethics and Dissemination: The scoping review involves analysis of the published literature on pain and advanced liver disease and does not require ethics approval. The results will be shared with expert stakeholders to help establish clinical significance. We will disseminate the findings through publication in a scholarly journal: local, provincial, national and international scientific and professional conferences., Prospero Registration Number: CRD42019135677., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

To identify actionable processes of care, quality indicators, or performance measures and their evidence base relevant to patients with persistent or chronic critical illness and their family members including themes relating to patient/family experience., Data Sources: Two authors independently searched electronic, systemic review, and trial registration databases (inception to November 2016)., Study Selection: We included studies with an ICU length of stay of greater than or equal to 7 days as an inclusion criterion and reported actionable processes of care; quality improvement indicators, measures, or tools; or patient/family experience. We excluded case series/reports of less than 10 patients., Data Extraction: Paired authors independently extracted data and performed risk of bias assessment., Data Synthesis: We screened 13,130 references identifying 114 primary studies and 102 relevant reviews. Primary studies reported data on 24,252 participants; median (interquartile range) sample size of 70 (32-182). We identified 42 distinct actionable processes of care, the most commonly investigated related to categories of 1) weaning methods (21 studies; 27 reviews); 2) rehabilitation, mobilization, and physiotherapy (20 studies; 40 reviews); and 3) provision of information, prognosis, and family communication (14 studies; 11 reviews). Processes with limited evidence were generally more patient-centered categories such as communication, promotion of sleep, symptom management, or family support. Of the 21 randomized controlled trials, only two were considered at low risk of bias across all six domains, whereas just two cohort studies and one qualitative study were considered of high quality., Conclusions: We identified 42 distinct actionable processes of care relevant to patients with persistent or chronic critical illness and their families, with most frequently studied processes relating to weaning, rehabilitation/mobilization, and family communication. Qualitative studies highlighted the need to address psychologic needs and distressing symptoms as well as enabling patient communication. Our findings are informative for clinicians and decision-makers when planning high-quality patient and family-focused care., Competing Interests: Dr. Rose’s institution received funding from Michael Garron Hospital Community Research Fund and the Ontario Respiratory Care Society. Dr. Connolly holds a National Institute for Health Research (NIHR) Post-Doctoral Fellowship and is supported by the NIHR Biomedical Research Centre based at Guy’s and St Thomas’s NHS Foundation Trust and King’s College London. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright (c) 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Purpose: To assess feasibility of producing intelligible and comprehensible speech with an electrolarynx; measure anxiety, communication ease, and satisfaction before/after electrolarynx training; and identify barriers/facilitators., Methods: We included tracheostomized adults from 3 units following commands, reading English, and mouthing words. On enrolment, we measured anxiety, ease, and satisfaction with communication. We gave electrolarynx instruction for ≤5 days then 2 independent raters assessed intelligibility, sentence comprehensibility (9-point difficulty scale), and Electrolarynx Effectiveness Score (EES), and re-evaluated anxiety, communication ease, and satisfaction. Interviews explored barriers/facilitators., Measurements and Main Results: We recruited 24 participants (Jan2015-Dec2016). Mean (SD) intelligibility was 45%(18%) words correct: 57%(21%) when facing. Mean comprehension difficulty was 6.4(2.0) overall, indicating moderate difficulty (5.5(2.5) scored visualizing). Mean EES was 2.9(1.0) (3 = improved lip-reading through recognizable sounds). Anxiety decreased from median 3.8 to 2.0 (P = .007). Communication was rated easier (median 15 vs 12, P = .04) whereas satisfaction remained similar (P = .06). Facilitators included device friendliness, patient independence, and word intelligibility. Barriers were patient weakness, difficulty positioning the device, and limited sentence as opposed to word intelligibility., Conclusion: The electrolarynx may aid intelligible speech for some tracheostomized patients if the communication partner can visualize the users face, and reduce anxiety and make patient perceived communication easier., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We sought to evaluate the effectiveness of a multi-component, case manager-led exacerbation prevention/management model for reducing emergency department visits. Secondary outcomes included hospitalisation, mortality, health-related quality of life, chronic obstructive pulmonary disease (COPD) severity, COPD self-efficacy, anxiety and depression.Two-centre randomised controlled trial recruiting patients with ≥2 prognostically important COPD-associated comorbidities. We compared our multi-component intervention including individualised care/action plans and telephone consults (12-weekly then 9-monthly) with usual care (both groups). We used zero-inflated Poisson models to examine emergency department visits and hospitalisation; Cox proportional hazard model for mortality.We randomised 470 participants (236 intervention, 234 control). There were no differences in number of emergency department visits or hospital admissions between groups. We detected difference in emergency department visit risk, for those that visited the emergency department, favouring the intervention (RR 0.74, 95% CI 0.63-0.86). Similarly, risk of hospital admission was lower in the intervention group for those requiring hospital admission (RR 0.69, 95% CI 0.54-0.88). Fewer intervention patients died (21 versus 36) (HR 0.56, 95% CI 0.32-0.95). No differences were detected in other secondary outcomes.Our multi-component, case manager-led exacerbation prevention/management model resulted in no difference in emergency department visits, hospital admissions and other secondary outcomes. Estimated risk of death (intervention) was nearly half that of the control., Competing Interests: Conflict of interest: None declared., (Copyright ©ERS 2018.)

Background: Approximately 5 to 10% of critically ill patients transition from acute critical illness to a state of persistent and in some cases chronic critical illness. These patients have unique and complex needs that require a change in the clinical management plan and overall goals of care to a focus on rehabilitation, symptom relief, discharge planning, and in some cases, end-of-life care. However, existing indicators and measures of care quality, and tools such as checklists, that foster implementation of best practices, may not be sufficiently inclusive in terms of actionable processes of care relevant to these patients. Therefore, the aim of this systematic review is to identify the processes of care, performance measures, quality indicators, and outcomes including reports of patient/family experience described in the current evidence base relevant to patients with persistent or chronic critical illness and their family members., Methods: Two authors will independently search from inception to November 2016: MEDLINE, Embase, CINAHL, Web of Science, the Cochrane Library, PROSPERO, the Joanna Briggs Institute and the International Clinical Trials Registry Platform. We will include all study designs except case series/reports of <10 patients describing their study population (aged 18 years and older) using terms such as persistent critical illness, chronic critical illness, and prolonged mechanical ventilation. Two authors will independently perform data extraction and complete risk of bias assessment. Our primary outcome is to determine actionable processes of care and interventions deemed relevant to patients experiencing persistent or chronic critical illness and their family members. Secondary outcomes include (1) performance measures and quality indicators considered relevant to our population of interest and (2) themes related to patient and family experience., Discussion: We will use our systematic review findings, with data from patient, family member and clinician interviews, and a subsequent consensus building process to inform the development of quality metrics and tools to measure processes of care, outcomes and experience for patients experiencing persistent or chronic critical illness and their family members., Systematic Review Registration: PROSPERO CRD42016052715.