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 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.

Objectives: 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.

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BackgroundMechanically 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 analysisWe 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.DiscussionTo 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.

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.

Aim To explore barriers to and facilitators for supporting communication with and for patients treated with invasive mechanical ventilation in the intensive care unit during the COVID‐19 pandemic. Design A qualitative descriptive study reported according to the Consolidated Criteria for Reporting Qualitative Research. Methods Adult intensive care unit patients treated with an advanced airway for mechanical ventilation, their family members and healthcare providers (nurses, intensivists and allied health) were recruited for interviews between January and April 2021. Interviews were audio‐recorded, transcribed verbatim and analysed using content analysis methods. Reported communication barriers and facilitators were mapped to the theoretical framework of acceptability to identify potentially modifiable clinical and institutional practices. Results We recruited 29 participants (20 healthcare providers, four patients and five family member). Provider communication barriers included isolation procedures, lack of personal protective equipment and inadequate communication tools/training, which reduced perceived communication frequency and effectiveness. Patients and families reported infrequent proactive provision of communication tools, which contributed to a crisis of unmet needs. Reported facilitators included adequate access to personal protective equipment to mitigate the risk of patient proximity and communication tools/training to improve communication effectiveness. Authentic unit leadership helped to assuage pandemic work stressors and encourage humanistic care. Our analysis indicates low acceptability of existing communication practices during the COVID‐19 pandemic and the importance of leadership to reduce the burden of communication through provision of key necessary resources. Conclusion COVID‐19 conditions have precipitated a communication crisis in the ICU. The results of this study have practice and policy implications and will be used to co‐design a communication intervention for use during and beyond the COVID‐19 pandemic. Impact The study contributes a better understanding of resources necessary to support patient communication. Results apply beyond the pandemic to routine use of infection prevention and control precautions in the intensive care unit.

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