Posttraumatic stress symptoms, sense of coherence and pain after intensive care treatment and the effect of early nurse-led follow-up consultations

Abstract

Mental and physical symptoms such as posttraumatic stress (PTS) symptoms and pain is common after treatment of critically ill patients in the intensive care unit (ICU). This can further develop to posttraumatic stress disorder (PTSD) and chronic pain and represent a severe health burden leading to reduced health related quality of life. Early identification of patients with the potential of developing PTSD is therefore important to be able to prevent or treat it. In addition, more knowledge about possible associations between PTS symptoms, pain, and sense of coherence (SOC, coping skills) after ICU discharge in a large general ICU sample is needed. We therefore aimed to measure the effect of nurse-led consultations in a pragmatic non-blinded randomized controlled trial (RCT) on reducing PTS symptoms and increase SOC the following year after ICU discharge in ICU patients with clinically relevant PTS symptoms (paper II). Furthermore, we intended to describe the occurrence of PTS symptoms at the hospital ward after ICU discharge, and investigate possible associations between PTS symptoms, SOC, pain as well as demographic and clinical variables in a large sample of discharged ICU patients (paper I). In paper III we investigated occurrence of pain at the hospital ward and the following year and associated variables in the same cohort of discharged ICU patients. Adult discharged ICU patients from five ICUs at Oslo University Hospital between 2014 and 2016 were included and screened for PTS symptoms at the hospital ward within a week after ICU-discharge (baseline). SOC and pain were simultaneously measured and all three scales were reevaluated after three, six and 12 months. Patients with clinically relevant PTS symptoms were randomized to the intervention group (IG, up to three nurse-led consultations within two months) or the control group (CG, receiving standard care only). Patients without clinically relevant PTS symptoms were included in the observation group (OG, also receiving standard care), and these patients were also available for papers I and III. In total, 523 patients were included and screened for PTS symptoms and available for papers I and III, and 224 patients were randomized to IG (111) and CG (113), respectively (paper II). There was a significant association between more PTS symptoms and lower SOC, higher pain interference with function, more delusional memories from the ICU, lower age and not being a trauma patient early after ICU discharge (paper I). Among patients with clinically relevant PTS symptoms early after ICU discharge, there was no significant difference in level of PTS symptoms or in total SOC score between IG and CG at three, six and 12 months after ICU discharge (paper II). However, PTS symptoms decreased, and SOC increased in both groups during the follow-up year (paper II). In total, 68% of discharged ICU patients reported worst pain intensity early after ICU discharge (paper III). At three, sixand 12-months follow-up, half of the patients still reported worst pain intensity. A statistically significant association was found between higher worst pain intensity and more PTS symptoms, female gender, shorter ICU length of stay (LOS), and more traumatic experiences from the ICU, during the follow-up year. For higher pain interference there was a similar statistically significant association, except for shorter ICU LOS. In addition, lower age and not being admitted with a primary medical diagnosis were also associated with higher pain interference (paper III). In conclusion, nurse-led consultations compared with standard care did not reveal any significant effect on PTS symptoms or SOC after ICU discharge in patients with clinically relevant PTS symptoms. Several discharged ICU patients experience PTS symptoms and pain in the following year after ICU discharge, although it seems to decline over time.