the icu diary - uni-heidelberg.de · the icu-diary –the icu-diary supports and stimulates the...

The ICU Diary

[email protected] Mannheim ANIM 2013 [email protected] Mannheim ANIM 2013

Rüdiger Haupt

Johannes Wesling Hospital

Minden/Nordrhein Westfalen

25% of my Job bedside nurse,

neurological and cardiological ICU

The ICU Diary

• 75% of my Job Teacher in the Academie of

health care and nursing in Minden

• Student of nursing sience, University of

applied sience in Jena 2009 – 2013 hopefully...


The ICU-Diary

What‘s that?

What‘s its meaning?

How to use it?


The ICU-Diary

• In many patients, staying in an intensive care unit

(ICU) facing the life-threatening situation, perishing

and death can cause similar psychological trauma

like being hijacked, taken hostage, or like torture,

war, terror and rampage experiences.

• In Germany up to 30% of all ICU patients develop

PTSD (Post traumatic stress disorder) between 2nd

and 6th month after intensive care treatment.


The ICU-Diary

• Symptoms of PTSD:

– Depression!!!

– Anxiety disorders

– Accomodation disorder!!!

– Changes in personality and character

– Attachment disorders

– Aggressive behavioral patterns

– Self-inflicted injuries

– Flashbacks!!!

– Suicidal tendency


The ICU-Diary

• A sequelae that does not strike us ….. but our

patients.

• But what has PTSD to do with the ICU-Diary?


The ICU-Diary

• Recalls of ICU patients:

– „I was laying in a bomb crater, in the middle of a

minesfield, pretending to be dead.“


I was on a camping ground above the cliffs of southern England.“


The ICU-Diary

• The Hemofilter sounds like the mechanical

milker in our cowbarn at home:


The ICU Diary

• Some patient support of crossing an ocean by

ship. (inflatable mattress)


The ICU Diary

• Others remembers epiditions to tropical

forrest. (humified oxygen)


The ICU-Diary

• Many refer to their distinct feeling being

dazed. Or of emotional numbness and

indifferences to other persons.

• Sense and perception change rapidly within

half an hour of a complete anergic state.


The ICU-Diary

Definition:

• The ICU-Diary is a document containing events,

changes and progress, written by health care staffs,

nurses, doctors and relatives during the time of

sedation and mechanical ventilation.

• The patient can read the log later, reconstructing

and comprehending the time of his/her

unconciousness and insensibillity.


The ICU-Diary

• Reports are given in an esteemed, honest

tone and summarized form: the incident

leading to admission and therapy of the

patient, as well as the up-to-date condition

and the progress of recovery.


The ICU-Diary

• Entries in the booklet can be done by

everybody involved in the treatment and care:

health care staffs like nurses, doctors,

physiotherapists, etc. , as well as relatives and

visitors.

• Expenditure of time for an entry is about 3-5

minutes.


The ICU-Diary

• Records should be done once every shift or

day.

• The first entry should contain a summarized

description of the events leading to

admission.


The ICU-Diary

• All further records should include changes,

therapeutic procedures, surgical interventions

(e.g. tracheotomia) and progress (e.g. physical

mobilisation).

• The surrounding and the noise background

should be described and whether

somebody/who has visited.


The ICU-Diary

• Reflexive questions can be posed, e.g.: „You

have breathed for the first time by yourself

and I wonder how it felt for you?“

• The entries should not be critical or negative

but esteemed and honest.

• They should not contain diagnoses!!!


The ICU-Diary

Studies / literature:

1. Bergbrom et al 1999

2. Bäckmann, Walther 2001

3. Akermann 2002

4. Combe 2005

5. Robson 2008

6. Storli, Lind 2007

7. Roulin 2007

8. Jones et al 2008


The ICU-Diary

• What‘s its meaning?

• Some statements of former ICU patients:

– „It gives me a good idea how things really were

[…] and where I have been. " 6

– „I realized how sick I was and what my family

experienced and went through.“ 5


The ICU-Diary

– " It means a lot to me that you [a nurse] were

thinking about my well being … and that you

cared for me. " (Storli et al 2003)

– " The diary and our talk give me a conception how

sick I really was and why my body has changed so

much."(ebd. 2003)


The ICU-Diary

• What is possible with the ICU-Diary, how is it

helpfull?

• Some study results:

– „The diary is helping to reconstruct the lost time

of the arteficial ventilation." 1,4,5,6

– "Patients and relatives assess the diary valuable." 1,2,3,4,5


The ICU-Diary

– „The diary demonstrates the solicitousness and

sympathy of the team." 7


The ICU-Diary

– Patients are enabled to give the event a sense and

purpose. 7

– The bereaved are helped to cope with the lost. 2


The ICU-Diary

– The ICU-Diary supports and stimulates the

conversation and communication in the family.4

– The diary seems to alleviate or avoid a possible

PTSD.8

– Reading diary reduces flashbacks. 8


The ICU-Diary

• Indications

– The diary can be used for almost all patients

sedated and ventilated for more than 3 days.

• Contraindication

– There are none definitive CIs, although it seems

not prudent to write a diary for patients not

familiar with the language or unable to read

(patients mentally retarded, patients with

dementia or aphasia).


The ICU-Diary

• Side effects:

– Sporadic reports about heavy emotional

reactions while reading the diary exist.


The ICU-Diary

• Statements :

– „Nevertheless - with the background of an ostensible

device dominant health care system we should not be

afraid to detect and name early enough causes and

sequelae of psychological trauma in ICU patients, to treat

them accordingly and to pay long-term respect to them.

Keep record in a diary is certainly a convincing approach."

– (Prof. Dr. Janssens, PD Dr. Graf: Angst und Depression

nach Intensivbehandlung: Hilfe durch Patiententagebuch?

Intensiv-News 2/09)


The ICU-Diary

• Applications of the ICU-Diary :

– In use in Scandinavia since 1984!!!

– Denmark: 19 / 48 ICUs, 39,6% (Egerod 2007)

– Sweden: 65 / 85 ICUs, 76,5% (Akermann 2008)

– Norway: 32 / 79 ICUs, 40,5% (Storli 2008)

– Germany: 0 / 1200 ICUs, 0,0% (Knück,Nydahl 2008)


The ICU-Diary

• Ready for the next step in evolution?


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