Patients surviving critical illness are at high risk of developing psychological problems after discharge, with as many as 10% developing symptoms of post-traumatic stress disorder (Wake & Kitchener, 2013), positively correlated with length of intensive care unit (ICU) stay. NICE recommends commencement of rehabilitation as soon as clinically possible in this group. Diaries have been shown to assist patients with fragmented delusional memories and difficulty recollecting their experience, and are hypothesized to work similarly to cognitive behavioural therapy. Factors including lack of awareness, time constraints and the non-compulsory nature has led to inconsistent staff engagement with the patient diary system at Medway Maritime Hospital.This project aimed to increase provision, consistency and overall multidisciplinary team (MDT) engagement with diaries for patients admitted to ICU for over 72 hours.
Plan - Do - Study - Act (PDSA) cycles were used as a method for quality improvement within this setting. The three cycles included; trialled methods included adding reminders to the online patient note system (Metavision), providing education sessions and raising awareness, and introducing a bedside guidance document to facilitate entry completion. Data was collected using information inputted to Metavision; a total of 129 patients were sampled over 105 days, with 77 receiving diaries.
Baseline average diary provision rate (26%) increased to 83% after the first PDSA cycle. During cycle two, we saw a further increase to 100%, with a subsequent decrease to 75%. However, final changes saw a return to 100% by the end of cycle three. Frequency of daily entry completion also increased, and physiotherapists (engaged in cycles 1 and 2) and an occupational therapist (engaged in cycle 2) completed entries alongside nurses.
Cost and savings
The project was run as a QI project as part of a KCL undergraduate module. Time was given by a mentor at Medway Maritime Hospital and minimal costs were absorbed by the department.
On three distinct data collection points, all patients admitted for over 72 hours received diaries. Also, an increased number and variety of the ICU MDT completed more regular diary entries. Although additional methods may be needed to ensure long term sustainability, we hope to have implemented effective changes.
As healthcare professionals we have the duty to make changes that will lead to better patient outcomes and better system performance. This quality improvement project is the first step into improving the pathway of the critical care pathway by engaging all members of the MDT to write regular and effective diary entries that patients may find helpful in their psychological recovery. Further research is required to evaluate the impact of these diaries entries and how the patient interprets and utilises these documents.
Top three learning points
- When implementing change, constant education and reinforcement is required to embed.
- Small changes with minimal costs can have a big impact.
- As a mentor to two medical students it was great to share my knowledge and experience of critical care and QI projects so they can develop as clinicians
Nil funding received
This work was presented at Physiotherapy UK 2017
For further information about this work contact Sarah Elliott.