Long-term patients in an ICU: How a new patient group emerges

Introduction

From its inception as a speciality area of clinical practice, intensive care has undergone constant advancement. This advancement shapes the practise of nursing in the intensive care unit (ICU). It also results in the emergence of ever-changing and new patient groups. As these new patient groups emerge, nurses are faced with the challenge of caring for vulnerable patients whose needs may be different, however, the model of care has yet to change to accommodate that difference. It is important to recognise how practice change related to advancement in the care of critically ill patients, such as the introduction of new medications, techniques, or technology, can have unintended and unforeseen consequences that may only be recognised years after their introduction. For every advance, there are consequences, and their multidimensional impacts can only be appreciated when healthcare professionals consider how their models of care need to constantly change to meet the needs of all patient groups, and their families.

A consequence of advances in life-sustaining therapies in the ICU is the emergence of a group of patients that survive their initial critical illness, only to then become dependent on life-saving interventions for a prolonged time, necessitating a protracted stay (Kahn et al., 2015). The international literature demonstrates that 5–10% of ICU patients have a prolonged stay, using 25–30% of ICU bed days (Ambrosino & Vitacca, 2018; Iwashyna et al., 2016) and resulting in a difficult clinical trajectory for patients, their family and healthcare professionals who provide their care (Minton, 2017). A protracted ICU stay is not a new phenomenon, but the patient group affected by this phenomenon has developed and changed since the inception of intensive care as a speciality. By viewing this ever changing group of patients retrospectively we can identify the challenges this group has on nurses’ practice, which is the first step to improve care.

Background to the concept of intensive care

The concept of intensive care can be linked back to Florence Nightingale, who created a separate area proximal to the nursing station for battle injured solders during the Crimean war (Fairman & Lynaugh, 2000; Grenvik & Pinsky, 2009). The expansion of large hospital wards in the late nineteenth and first half of the twentieth century saw the most seriously ill patients separated into semiprivate areas and often cared for by special duty nurses. As early as 1927, in an attempt to improve care, a specialised area for post-operative neurosurgical patients was established in a hospital in the United States and the concept of a specialised site for the care of the seriously ill patient expanded. Specialised sites of care for high risk patients were further expanded during World War II as so-called shock units evolved (Weil & Tang, 2011). With increasing acuity of patients, the intensive observation practised by nurses was critical to patient outcomes, resulting in nurses increasing their skill level to cope (Fairman, 1992).

Polio epidemic of the 1950s

The polio epidemic of the 1950s is cited as the beginning of intensive care, perhaps due to the increased presence of medical staff, but nursing practices with sicker patients, formed the model for ICU services that developed during the 1950s (Fairman, 1992; Marini, 2013). The iron lung prolonged life, therefore creating a new cohort of long-term, ventilator-dependent patients. Without the iron lung these patients would have died, but this equipment did not provide the necessary airway protection and the mortality rate from polio with respiratory failure remained very high at 85%–90%. During the Copenhagen polio epidemic there were high mortality rates despite the use of the iron lung. That led to the development of intermittent positive pressure ventilation (IPPV) through a cuffed tracheostomy tube that saw the mortality rate drop from over 80% to 40% under this new treatment (Marini, 2013).

Impact of the development of IPPV

Following the successful outcomes from the use of IPPV in Copenhagen, news of this treatment spread internationally and resulted in a 16-year-old girl with Guillain-Barre syndrome in the United Kingdom being treated with this new intervention. There was much unease about the ethicality of keeping someone alive whose senses and reason where intact but who was unable to move their body, especially with the knowledge they might not recover (Crocker, 2007; Le Fanu, 2001). However, the patient did recover after being ventilated for six weeks and her survival was a milestone in the development of intensive care medicine, as it could never again be questioned about the use of positive pressure ventilation for patients with respiratory failure. The survival of this patient also illustrates how technological advances create new patient groups that then challenge clinicians’ practice. Following from the establishment of IPPV its use developed, but an important dilemma was recognised: what to do when a patient on IPPV to prevent death, then did not recover, leaving them reliant on IPPV (Reiser, 2009).

The chronically critically ill

The cumulative effects of technology and medical advances are further highlighted in the literature in relation to patients with a prolonged critical illness, when in 1985, Girard and Raffin (1985) describe a new group of patients, the chronically critically ill. They acknowledge a number of complexities relating to their care, firstly the ethical challenges related to care for patients with poor outcomes, secondly, the physiological impact of critical illness on body systems, and finally the unsuitability of a fast-paced ICU environment as the site of care. This group of patients became recognised as having a syndrome characterised by respiratory failure and other multi-organ dysfunction, requiring prolonged mechanical ventilation, (Campbell & Happ, 2010; Nelson, Bach, Cox, Hope, & Carson, 2010; Wiencek & Winkelman, 2010). The difficulties of caring for this group of patients was noted (Daly, Rudy, Thompson, & Happ, 1991) and the need recognised for evidence-based care for interventions to manage this group of patients. As a result research programmes developed.

Persistent critical illness

Iwashyna et al. proposed that a new growing group of patients within Australian and New Zealand ICUs appeared to be ICU-dependent because of a cascade of critical illness rather than their original ICU admitting diagnosis. These patients were labelled as suffering from a persistent critical illness (PerCI). Those authors identified characteristics of this patient group with PerCI as developing after a median of 10 days in the ICU, occurring in 10% of all ICU patients, and affecting 50% of all patients with a prolonged ICU stay (Iwashyna, Hodgson, Pilcher, Orford, et al., 2015).

The consequences of advancements in life-sustaining technology on nurses’ practice

Because intensive care is at the forefront of medical and technological advancements it is a domain where new challenges and changing patient groups converge. Medical and technological advances have enormous power, resulting in an inability to always control consequences. As advancements can occur slowly nurses can fail to recognise the consequences and fully critique the impacts on their practice, which can result in nurses noticing patients to be challenging to care for but perhaps not fully understanding the reason why.

The difficulties of caring for unstable or disfigured or comatosed patients have been reported in the literature since the development of ICUs in the 1950s (Fairman, 1992; Wiles & Daffurn, 2002). Although many early ICU patients recovered, the impact of caring for some patients for a prolonged period of time created a sense of helplessness and frustration for some nurses. In an effort to deal with the emotional impact of caring for critically ill patients, nurses attempted to gain more knowledge of physiological aspects of patient care, as most of their education had only focused on the functional aspects of their work (Fairman, 1992).

This sense of helplessness and frustration has continued to be reported in the literature in relation to care of patients with a prolonged critical illness. The burden and emotional distress while caring for long-term ICU patients has been reported in a number of studies (Leung et al., 2015; Minton, 2017; Roulin, Boul'ch, & Merlani, 2012; Siffleet, Williams, Rapley, & Slatyer, 2015). Distress was also reported when nurses felt they had to deliver care that prolonged life and caused the patient undue suffering (Leung et al., 2015). Distress was also reported when care delivery was of a complex nature (Siffleet et al., 2015).

The value of health care advances can only be fully achieved when nurses can interpret them with understanding of the consequences, both intended and unintended, that they bring to the patient, their family and other healthcare professionals. Since the inception of the speciality of intensive care medical and technological advances have challenged patients, their families and healthcare professionals. Throughout the history of the intensive care specialty, nurses’ responses to these advances are often invisible, although nurses will be actively dealing with the human impacts. The key principle is to recognise the constant changing landscape and to have the ability to critique the impact of these changes on clinical practice and patient outcomes.

Conclusion

The dominant force advancement has influenced nurses’ practice in the ICU since its inception. Nurses need to be prepared to reflect and evaluate practice to recognise the burden this can create, which can ultimately affect the delivery to patients and families. Advancement will continue to play an important role in the ICU as new treatments continue to challenge healthcare professionals who work in this area.