the psychological impact of picu admission on the familypicupsychology.net/docs/us research2.pdf ·...
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The psychological impact ofPICU admission on the family
Gillian ColvillePediatric Psychology Service
St George’s Hospital, London UK
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Why look at this group?
• Theoretical high risk of PTSD in childrenand parents
• Potential for preventative work andintervention
• Predictable steady workload (as comparedwith after disaster)
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Inherent Difficulties
• Patients unconscious
• Carers in extreme distress (?capable ofinformed consent)
• High risk of death
• No formal follow up structure
• High proportion of deprived families
• Majority of patients aged under 5y
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Plan
• Literature on Children
• Research at St George’s and Great Ormond St
• Literature on Parents
• Research at St George’s and Great Ormond St
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Children
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Literature on children
Growing interest in outcomes after ICUgenerally, and in rates of post traumaticstress symptoms in paediatric populationsand their parents .
Potential stressors
1) pre admission - acute illness/ accident
2) admission - invasive procedures, pain,witnessing others’ distress
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Adult ICU findings• Menzel (1998) fear tube in situ
• Schelling et al (1998) long lasting PTSD
• Scragg (2001) link between ICUexperiences and PTSD
• Jones et al (2001) on link betweendelusional memories and PTSD
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Child ICU findings: short term
• Only 67% remember anything,predominantly neutral/positive (n=40)
Playfor et al (2000)
• 100% remembered something, 50%negative memories (n=50)
Karande et al (2005)
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Child ICU findings: longer term• PTSD higher in children (52% v 9%) 6-8 wks
after critical illness
Landolt et al (1998)
• PTSD higher in children (26% v 0%) 6-12m aftercritical illness (n=35)
Rees et al (2004)
• Association between no. of invasive proceduresand PTSD symptoms at 6 months (n=60)
Rennick et al (2004)
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Research on Children
1) Pilot interviews with SGH child survivorsaged over 7 (n=15)
2) Interviews with GOS child survivors
3 mths and 1yr after discharge (n=102)
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1) Pilot Interviews @ 8 mths (n=15)
• 13/15 could remember the admission
• 4/15 scoring above cutoff for PTSD
at 9 months
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Children’s Quotes
“I feel like I am the odd one out of
everybody”
“I am not as scared as I was …now when I
get a cut it is just nothing”
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Fear Schedule SD scores
SD
2.502.001.501.00.500.00-.50-1.00-1.50-2.00-2.50
Fre
qu
en
cy
6
5
4
3
2
1
0
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Children’s Quotes
“I fell asleep and dad was holding my handand then I saw these people getting theirheads chopped off”
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2) Children’s Memories Project(n=102)
• Relationship between memories and posttraumatic stress
• Relationship with parental distress
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Great Ormond Street Hospital
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Design
• Interview at 3m
• Telephone follow up at 1y
Also collected measures of parent’s posttraumatic stress, anxiety and depression atboth timepoints
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Psychological measures
• Child Revised Impact of Event Scale (posttraumatic stress)
• ICU Memory Tool (factual v delusionalmemories)
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Sample
• Survivors over 7 years of age (n=102/132)
Exclusions
• Learning difficulties; readmitted to PICU;professional refusal (eg palliative care);long term ventilation; self-harm
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Reason for admission
Elective surgery
Trauma
Other
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Factual Memories
63% remember some aspect of admission
• Pre PICU
accident, collapse, feeling unwell
• During PICU
family, staff, machines, (breathing tube 20%)
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Factual Memories
63% remember some aspect of admission
• Pre PICU
accident, collapse, feeling unwell
• During PICU
family, staff, machines, (breathing tube 20%)
• Post PICU
ward, injections, ambulance to local hospital
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“It was very hard to be sick lying downobviously…”
13y boy, head injury
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Delusional Memories (1 in 3)
• “This isn’t my head!” “Where are my fingers?”
• Rats in cups moving across the wall
• Parents replaced by impostors
• Staff trying to kill patient
• Terrorist attack
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“When I came back from the hospital I wasseeing lots of things on the walls…..Umwherever I looked I would see some things
……Yea crawly things”
10y girl, cancer
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“Scorpions everywhere! On my feetand on the walls – then when I woke upagain I could see through them.”
10 year old boy (RTA)
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Post traumatic stress symptoms
“Came into my mind and sort of like a videoclip and going towards the edge yes andthen the whole of my body just chuckeditself forward as if I was crashing. It wasreally weird”
13y boy, head injury
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3 mths
• Emergency admission (p<0.01)
• Delusional memories (inc hallucinations)
(p<0.05)
1yr
• Post traumatic stress score at 3m (p<0.01)
Predictors of Post-traumaticstress
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0%
10%
20%
30%
40%
50%
3 mths 1 year
new case
case at 3m
Post traumatic stress cases
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Main findings (1)
• Significant minority of children recallhallucinations and bizarre dreams duringhospital stay
• Hallucinations and emergency admissionpredict Post traumatic stress at 3 mths
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Main findings (2)
• Post traumatic stress at 3 mths strongestpredictor of score at 1y
• Half of post traumatic stress cases at 1y areNEW cases
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Parents
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Literature on Parents
Carter & Miles (1989) Parental Stressor Scale(PSS:PICU) – 7 dimensions of experience
Child’s appearance Sights and Sounds
Procedures Parent’s role
Child’s behaviour Staff behaviour
Staff Communication
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Board & Ryan-Wenger (2002)
• PICU mothers (n=31)significantly moredistressed than general ward mothers (n=32)6 months after discharge
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Rees et al (2002)
• 27% PICU parents (n=33) screened positivefor PTSD compared to 7% general wardparents (n=29), 6-12 mths post discharge
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Baluffi et al (2004)
• 272 parents completed stress questionnaireon discharge
• 161 followed up at 4 mths
• 21% PTSD at follow up
• PTSD correlated with distress at dischargebut not with illness severity (PRISM)
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Research on Parents
1) Mixed method interview study at 8months (n=34 mothers, n=18 fathers)
2) Longitudinal study of child-parent pairs
seen at 3mths and 1yr (n=66 pairs)
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1) Parent Interview @ 8 monthsn=34 mothers; 18 fathers
• Recollections of admission - stress and coping
• Current distress
• Views on follow up
Colville GA & Gracey D (2006)Intensive and Critical Care Nursing 22 (1) 49-55
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QUANTITATIVE DATA
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Mothers’ and Fathers’Post Traumatic Stress scores
1717N =
FA THERSMOTHERS
60
50
40
30
20
10
0
7
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Association between talking attime and stress at follow up
no yes
Talked about experience at the time
0
20
40
60
80
To
tal
Imp
act
of
Ev
ent
Sca
le(I
ES
)sc
ore
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Type of follow up desired(n=52/54)
Medical
10%
Medical + psychological
29%
Psychological
29%
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QUALITATIVE DATA
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QUOTES: CHILD’SAPPEARANCE
• “she looked totally drugged, dazed, gone,she was just out, puffy”
• “she just looked horrific, bright red face,tubes coming out of every possible place “
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“she was so bloated and she looked terrible, Ijust could not make myself to go near her.
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QUOTES: TRANSFER TOWARD
• “planets apart “
• “The room from hell. When I saw it, Icouldn't stop crying . “
• “The difficulties were … before and after.PICU itself was fine”
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Transfer to General Ward
• Responsibility for child’s care
• Child’s emotional demands
• Parents’ resilience
• Level of staffing
• Staff expertise
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QUOTES: POSITIVE ASPECTS
“Because of the accident, he is very, very, special tome. ”
“We saw the best of people during
that time”
“ I re-valued my life totally. This house could burndown tomorrow as long as my family stood outthere I wouldn't worry ”
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Staff behaviourthat parents appreciated
• “I just thought they were all fantastic, theynever did anything without letting youknow what they were going to do”
• “They were very good with us even whenwe asked silly questions”
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• “They weren’t patronising,they were justnormal and nice”
• “All the staff there were very good, if youwanted to talk you talk, if you didn’t wantto talk you didn’t.”
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Difficult Staff Behaviour
• Conflicting Information
“You do tend to get completely conflictinganswers from two different doctors”
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• Not knowing who people were
“When they do introduce themselves theysort of mumble their names and you thinkwho the hell was that!”
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• Perceived Criticism of child or parent
“She sort of implied that X had been a bit ofa nuisance by not settling down”
“We were made to feel a little bit as thoughwe were neglecting her by not staying in”
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• Anxiety re staff inexperience
“Everyone has got to learn , but not when itis my child”
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2) Child-parent pairs at3mths and 1yr
n=66 pairs
Post-traumatic stress symptoms assessed at 3months and 1 year post discharge
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Parent PTS
Post Traumatic Stress above cut off
0%
5%
10%
15%
20%25%
30%35%
40%45%
50%
3 months 1year
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Parents: new cases at 1 yr
0%
10%
20%
30%
40%
50%
3 mths 1 year
new case
case at 3m
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Parent and Child
Post Traumatic Stress
0%
10%
20%
30%
40%
50%
3 months 1year
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3 mths
• Emergency admission (p<0.001)
1 yr
• Emergency admission (p<0.001)
• PTS score at 3m (p<0.001)
• Anxiety score at 3m (p<0.001)
• Depression score at 3m (p<0.001)
Predictors* of Post traumatic stress:Parents
* Spearman correlations* Spearman correlations
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Spearman correlations for PTSscores (n=66)
parent PTS
child avoid
child intrus
3m 1y3m 1y
0.020.02
--0.080.08
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Spearman correlations for PTSscores (n=66)
parent PTS
child avoid
child intrus
3m 1y3m 1y
0.38**0.38**
--0.080.08
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Post traumatic stress patterns at 1year
or
child ok
parent ok
child PTS
parent PTS
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Other research
• RCT evaluation of follow up clinic
• Post traumatic growth in parents after PICU
• Parents’ experiences of retrieval
• Screening for risk of PTSD
• Gender differences in parents’psychological reactions
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Colville GA . The impact of admission topaediatric intensive care unit (PICU). In :The Psychological Challenges ofIntensive Care. S Ridley ed. CriticalCare Focus Series, BMJ Books (2005)
Colville G. The psychological impact onchildren of admission to intensive care.Pediatric Clinics of North America (inpress, June 2008)
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Research funded by St George’s Charitable Foundation,Paediatric Intensive Care Society and The Health Foundation
Thank you