Background Intensive care unit survivors often have diminished health-related quality of life. Objectives To describe health-related quality of life of former intensive care patients and identify associated factors 6 months after hospital discharge. Methods Six months after discharge, 193 patients from an intensive care unit completed the Short Form-36 Health Survey; measures of sleep; Intensive Care Experience Questionnaire; Depression, Anxiety and Stress Scales; and Posttraumatic Stress Disorder Checklist. Norm-based scores were calculated for the Short Form-36. Bivariate associations with Short Form-36 scores were tested by using the Pearson correlation. Multiple linear regression was used to identify independent associations with health-related quality of life. Results All scores on the Short Form-36 (physical component summary, 41.8; mental component summary, 48.2) were less than population norms. Bivariate associations with health-related quality of life ( P < .05) were scores on the Acute Physiology and Chronic Health Evaluation II, hospital length of stay, awareness of surroundings and frightening experiences, depression, anxiety, stress, posttraumatic symptoms, and sleep quality at 2 and 6 months. In linear regression, scores on the Acute Physiology and Chronic Health Evaluation II, hospital length of stay, and sleep quality at 6 months were independently associated with Short Form-36 physical summary scores ( P < .001); depression and stress were independently associated with mental summary scores ( P < .001). Conclusion Sleep, depression, and stress are potential targets for interventions to improve health-related quality of life and improve recovery.

Background Some survivors of critical illness experience poor physical recovery, but which patients experience the most compromise during recovery is unknown. Objective To identify factors associated with physical recovery by using the 6-minute walk test in adult survivors of critical illness 26 weeks after discharge from the hospital. Methods A total of 195 adult survivors of a critical illness were enrolled in a multicenter trial of physical rehabilitation after discharge from the hospital. The 6-minute walk test, the 36-Item Short Form Health Survey, and sleep rated on a 5-point scale were completed at weeks 1 and 26. Clinical and demographic data were obtained from patient records. Results A total of 145 patients completed the 26-week test. Of these, 94 (65%) increased the distance walked in 6 minutes by at least 75 m from the 1-week value and were therefore considered to have improved on the test. Factors associated with improvement included moderate to severe sleeping problems in week 1, moderate to vigorous exercise in week 26, and higher vitality in week 26. Conversely, respiratory problems and higher social functioning in week 1 were associated with less improvement in the distance walked. Conclusion Multiple factors are associated with physical recovery after critical illness. Interventions to target multidimensional aspects of recovery such as sleep and exercise may result in improved physical function after critical illness.

Background Daily interruption of continuous infusion of sedatives has improved outcomes in patients receiving mechanical ventilation in open-label studies. Objectives To assess the feasibility of a protocol for a double-blind, randomized, controlled trial study on the impact of routine daily interruption of sedation in patients receiving mechanical ventilation. Methods A total of 50 patients receiving mechanical ventilation were randomized to daily interruption of fentanyl and/or midazolam infusions for up to 6 hours or to usual management of sedation. Blinding was achieved by using replacement infusions (saline or active drug in saline). Results The recruitment target of 80 patients was not met in an extended time frame. Propofol was used outside the protocol in 27% of patients in the intervention group and 17% of patients in the control group ( P = .10). A total of 15% of the intervention group and 12% of the control group never had replacement infusions started ( P = .77), and replacement infusions were started on only approximately one-third of eligible days in patients who received replacement infusions. The mean doses of fentanyl and midazolam were similar. The blinding strategy was safe and effective: no patients had unplanned extubations, and the most frequent reason for ending replacement infusions was completion of the maximum 6-hour period. Conclusions The double-blinded design for assessment of sedation interruption in patients receiving mechanical ventilation was safe and effective. Slow recruitment of patients and frequent noncompliance with the protocol suggest that modifications to the protocol are needed.

Background Critically ill patients are at increased risk for pressure ulcers, which increase patients’ morbidity and mortality. Quality improvement projects decrease the frequency of pressure ulcers. Objectives To improve patients’ outcomes by reducing the prevalence of pressure ulcers, identifying areas for improvement in prevention of pressure ulcers, and increasing the adoption of preventive strategies in an intensive care unit. Method Quasi-experimental methods were used for this quality improvement project in which 563 surveys of patients’ skin were performed during 22 audits conducted during a 26-month period. One-on-one clinical instruction was provided to bedside nurses during the surveys, and pressure ulcer data were displayed in the clinical area. Results The frequency of pressure ulcers of all stages showed an overall downward trend, and the prevalence decreased from 50% to 8%. The appropriate allocation of pressure-relieving devices increased from 75% up to 95% to 100%. The likely origin of the ulcer (ie, whether it was hospital or community acquired) and the anatomical site of the pressure ulcers did not change during the study period. Conclusions This program was successful in reducing the prevalence of pressure ulcers among vulnerable intensive care patients and indicates that quality improvement is a highly effective formula for improving patients’ outcomes that is easily implemented by using clinical expertise and existing resources.

Background Patients undergoing coronary artery bypass surgery who have increased anxiety levels have poorer outcomes than patients with lower levels, yet few studies have identified the concerns associated with this anxiety. Objective To describe the concerns of patients undergoing coronary artery bypass surgery and to identify concerns that were associated with higher levels of anxiety. Method Patients (n = 172) were interviewed to determine their concerns and anxiety levels before surgery, before discharge, and 10 days after discharge. Multiple regression was used to determine the predictors of anxiety. Results Although individual concerns changed over time, anxiety levels did not change from before to after surgery, remaining low to moderate. Being female and having more concerns about waiting for the surgery, being in pain/discomfort, and resuming lifestyle were predictors of increased anxiety before surgery. Predictors of increased anxiety while hospitalized after the surgery included taking anxiolytic or antidepressant medications, higher anxiety levels before surgery, concerns about personal things being inaccessible, and difficulty sleeping. Patients with higher anxiety levels after discharge were older, more anxious before surgery, and had concerns about being in pain/discomfort. Conclusion Patients waiting for coronary artery bypass surgery should be routinely assessed for anxiety before the procedure, and interventions to prevent or reduce anxiety should be provided. Interventions must be multifactorial, including information and support for pain management and realistic information about surgery schedules and resuming lifestyle after the surgery. Women and older patients may need to be targeted for intervention.

• Background Increased anxiety correlates with increased complications after acute myocardial infarction. Anxiety levels and use of anxiolytic agents have not been compared between smokers and nonsmokers hospitalized because of acute myocardial infarction. • Objectives To compare anxiety level, sociodemographic factors, and clinical variables between smokers and nonsmokers hospitalized with acute myocardial infarction and to examine predictors of use of β-blockers and anxiolytic agents among smokers and nonsmokers. • Methods Secondary data analysis of a prospective multisite study on anxiety in 181 smokers and 351 nonsmokers with acute myocardial infarction. Anxiety was measured by using the State Trait Anxiety Inventory and the anxiety subscale of the Basic Symptom Inventory within 72 hours of admission. • Results Smokers reported higher anxiety levels than nonsmokers reported on both anxiety scales. Female smokers reported the highest anxiety and peak pain levels of all, yet women were the least likely to receive anxiolytic agents. Smoking status was not a predictor for anxiety level when sex, peak pain, use of β-blockers in the hospital, and age were controlled for. However, smokers were twice as likely as nonsmokers to receive an anxiolytic agent and 60% more likely to receive a β-blocker in the emergency department, and smokers were 80% more likely than nonsmokers to receive an anxiolytic agent during hospitalization when these variables were controlled. • Conclusions Older female smokers are at risk for complications because they are older than their male counterparts and less likely to receive β-blockers and antianxiety medications in the emergency department.

• Background Anxiety is difficult to detect in patients receiving mechanical ventilation because clinical signs are confounded and patients often cannot respond to validated anxiety measures. Most patients can respond to the single-item Faces Anxiety Scale. • Objectives To assess the validity of the Faces Anxiety Scale, the frequency and severity of state anxiety, and correlates of anxiety in intensive care patients. • Methods A research assistant made a single clinical judgment of anxiety in the range of 1 to 10 on the basis of patients’ nonverbal responses (ie, nods) to 9 questions about mood and their physical and behavioral signs. Patients then responded to the Faces Anxiety Scale. Demographic, clinical, and pharmacological data were obtained from the patients’ charts. • Results Mean age of the 106 patients was 61 years; 62% were men. Admission diagnoses were cardiovascular in 26% of patients, respiratory in 26%, trauma in 18%, neurological in 12%, gastrointestinal in 12%, and other in 6%. At the time of anxiety assessment, 89% were receiving mechanical ventilation. The correlation between patients’ self-reports of anxiety on the Anxiety Faces Scale and the research assistant’s assessments was 0.64 ( P < .001). Some anxiety was reported by 85% of patients (mean level 2.9; SD 1.2). Anxiety levels were lower in patients who had recently received sedatives or opioids but were not related to heart rate or blood pressure. • Conclusions The Faces Anxiety Scale is a valid means of measuring anxiety in intensive care patients. Anxiety is common in these patients and is often moderate to severe.

• Background Anxiety is associated with increased morbidity and mortality. Critical care nurses are uniquely positioned to reduce anxiety in their patients. Critical care nurses’ beliefs about and frequency of use of strategies to reduce anxiety have not been studied. • Objectives To explore critical care nurses’ beliefs about the importance of anxiety management and to describe nurses’ reported use of strategies to manage anxiety in their patients. • Methods A random sample (N = 2500) of members of the American Association of Critical-Care Nurses was asked to complete the Critical Care Nurse Anxiety Identification and Management Survey. • Results Respondents (n = 783) were primarily female (92%), white (88.5%) staff nurses (74.1%) who thought that anxiety is potentially harmful (mean, 4.1; SD, 0.8; range, 1 = no harm to 5 = life-threatening harm), that anxiety management is important (mean, 4.8; SD, 0.6; range, 1 = not important to 5 = very important), and that effective anxiety management is beneficial (mean, 4.6; SD, 0.6; range, 1 = no benefit to 5 = profound benefit). A majority commonly used pharmacological management; most also used information and communication interventions. Fewer subjects used the presence of patients’ family members to alleviate patients’ anxiety; few reported using stress-reduction techniques. • Conclusion Most respondents thought that treating anxiety is important and beneficial. Commonly used strategies included pharmacological relief of anxiety and pain and information and communication interventions. Although these strategies are useful, they may not effectively reduce anxiety in all patients.

• Background Anxiety activates the sympathetic nervous system and hypothalamic-pituitary-adrenal axis and may increase morbidity and mortality in vulnerable critical care patients. Despite the adverse effects of anxiety, little is known about critical care nurses’ practices for assessing anxiety. • Objective To determine the importance that critical care nurses place on evaluating anxiety and to describe clinical indicators used to assess anxiety. • Methods Twenty-five hundred members of the American Association of Critical-Care Nurses received the Critical Care Nurse Anxiety Identification and Management Survey and were asked to rate the importance of anxiety assessment, to rate the importance of 61 anxiety indicators, and to select and rank the 5 most important anxiety indicators. • Results Seven hundred eighty-three completed surveys (31.6%) were returned by female (92.0%), white (88.6%) staff nurses (74.2%) who practiced critical care nursing 32.5 hours (SD, 12.3 hours) weekly. Nearly three quarters (71.3%) of respondents thought that anxiety assessment is very important. Only 2 indicators, agitation and patients’ verbalization of anxiety, were rated as very important to anxiety assessment. Thirty-nine indicators rated as important primarily included measurable physiological changes and observable behaviors. The top 5 anxiety indicators were agitation, increased blood pressure, increased heart rate, patients’ verbalization of anxiety, and restlessness. • Conclusion Important indicators of anxiety included observable behaviors and measurable physiological changes. Reliance on these criteria may produce an inaccurate and incomplete anxiety evaluation in vulnerable patients and lead to poorer outcomes. A comprehensive, systematic anxiety assessment tool for valid and reproducible evaluation of patients’ anxiety is needed.