Sri Lanka Medical Association Presidential Address 2006:

Stress the ogre in ICU

by Dr. Suriyakanthie Amarasekera

I would like to share with you an encounter that I had with a patient many years ago, when I was a young medical student that made a lasting impression on me.

This mother of two young children had been suddenly and tragically struck down with a rapidly progressing paralysis. She was rushed to the General Hospital Colombo, soon she developed difficulty in breathing and needed ventilatory support. She was connected to the one and only ventilator available in GHC at that time and nursed right next to the nurses station in the Neurosurgical ward located on the 4th floor of the Bandaranaike building.

When I met her, she had been weaned off the ventilator, and was breathing adequately by herself, but still had grade III weakness of all four limbs.

The consultant in charge of the ward had printed in large block letters a board which said "every day in every way I am getting better and better" and hung it up at the foot of her bed. It was the first thing she saw when she woke up each morning and the last thing she saw before she fell asleep.

Encouraged by the medical and nursing staff, fellow patients and us humble medical students, she worked hard to regain the use of her limbs. I remember clearly the day she triumphantly placed a perfectly circular red Kum Kum at the centre of her forehead. All of us standing round her clapped and cheered. She made a complete recovery and was discharged to return home one happy day, to lead a normal life.

Caring for critically

Those of you who are involved in caring for critically ill patients would no doubt shudder and throw up your hands in horror at the way in which this young patient had to be managed.

There were no Intensive Care Units in existence in those days, and there was no alternative but to care for this patient in an open ward, without any of the sophisticated equipment that is readily available to us now.

Having been actively involved in the care of critically ill patients in Intensive Care Units for the past three decades both here in Sri Lanka and in England, and being the Consultant in Charge of the General Intensive Care Unit at Sri Jayewardenepura Hospital from 1992, I cannot help but feel that the well equipped Intensive Care Units of today are now lacking an important aspects of patient care that were available 40 years ago.

Intensive Care has been defined as a service for patients with potentially recoverable diseases, who can benefit from more detailed observation and treatment that is generally available in the standard wards and departments Sipby 1989.

An Intensive Care Unit is a specially staffed and equipped hospital ward that is dedicated to the management of patients with life threatening illnesses injuries or complications.

The original concept of rounding up all seriously ill patients in a hospital to one location was the inspiration of the Nursing Legend Florence Nightingale. It has been suggested that Intensive Care Units developed from the Post Operative Recovery Rooms and the polio epidemic in the 1950's when the use of long term artificial ventilation resulted in reduced mortality.

Modern Intensive Care however is not limited to post operative care or mechanical ventilation. It is a specialty which has evolved from the experience of respiratory and cardiac care and physiological organ support. Coronary Care Units were established in the 1960's to monitor rhythm disturbances in cardiac patients, followed by units to manage patients after open heart surgery. Thereafter the stage was set for the development of various specialised units.

Sri Lanka was quick to follow the lead given by the western world and the first Intensive Care Unit in our country was established in 1968 in the General Hospital Colombo due to the pioneering efforts of Dr. Thistle Jayawardane, one of the distinguished past presidents of the SLMA. This was a six bedded Surgical Intensive Care Unit that was primarily intended for the care of patients following cardiac surgery.

Since then many ICUs have been established throughout the length and breadth of Sri Lanka. There are at present 52 ICUs in hospitals in the National Health Service scattered throughout the island. While many are located in Teaching hospitals, there are units in General, Provincial, Base and Special hospitals. In addition to these, there are units in the Army, Navy and Police hospitals as well as in the private sector.

So at any given time one could assume that about 400 patients are receiving Intensive Care in our country.

These critically ill patients have life threatening conditions which require life support mechanisms extensive treatment, and close monitoring which is available within an Intensive Care Unit.

With the technological expansion and advancement of science in the field of Critical Care in the past three decades an era has dawned where, Intensive Care Units can be referred to as an arena for punitive survivalists. There is no doubt that clinic have developed an increased ability to improve the quality and quantity of life for patients in the long term, post discharge. But it is also a fact that patients and their families often suffer more than is necessary in a short term, during the critical care phase of their illness.

Despite receiving sedative drugs, many critically ill patients experience anxiety because of the seriousness of their condition, and the nature of the treatment procedures they undergo as well as the Hi tech environment of the ICU.

Anxiety is defined as a subjective experience which signals that a threat of some type has stimulated the stress response. The subjective feelings associated with anxiety include apprehension, feelings of uncertainty and uneasiness.

At its simplest level, stress can be defined as a response to any stimulus.

This response will vary with the experience and perception of each individual. The response of the body to psychological stress does not differ from that to physiological stress.

The response to psychological stress has been assessed in individuals taking their first parachute jump. In these individuals the standard fight or flight response - is initiated not by physiological stimulus but by fear, which is a psychological stimulus.

The initial fight or flight response occurs at the first exposure to a stimulus. If the stimulus persists, adaptation will occur and a stage of resistance develops where the response to the stimulus is unnoticed.

If the stimulus persists further, however an exaggerated or abnormal response occurs which leads to a stage of exhaustion. This abnormal response is usually manifested as fear, anger or a mixture of the two, but the expression will vary with the individual. Increased irritability, denial of a problem possibly by using drugs or alcohol, and self destructive or dangerous behaviour such as workaholism, or smoking are frequently observed.

So the response to a stimulus is mediated by factors within each individual, and these determine the final outcome. That is why different individuals find different stimuli stressful and manifest their stress indifferent ways. We all require stimulation in our lives. Indeed stress allows us to learn from new experiences.

Patients are physiologically stressed by their illness. This is an appropriate response of the body in promoting recovery.

The consequences of the psychological stresses arising from the patient's illness however are not yet clearly understood. Critically ill patients are unable to communicate effectively during their illness. Their stress levels have been established retrospectively in several studies investigating memories of patients who have received intensive care.

These have revealed that whilst in ICU, patient have experienced high levels of anxiety, depression, boredom and fatigue.

Though these retrospective studies are of value, it would be of greater advantage to be able to measure anxiety in patients while they are receiving treatment in an ICU. This will not only help in evaluating the response to measures taken to reduce anxiety, but also potentially enhance recovery by indicating anxiety levels that need to be actively treated.

Anxiety can be assessed by:

1. Observation of physiological signs

2. Observation of behavioral signs

3. Self report by patients.

Physiological and behavioral signs of distress such as tachycardia, raised blood pressure and restlessness are difficult to interpret in critically ill patients, where other etiological factors need to be taken into consideration. Similarly alterations of biochemical markers of stress such as cortisol, and catecholamine, may be attributable to physiological stress and difficult to interpret.

Self report by patients while in ICU is a reliable measure of anxiety. But patients receiving intensive care are often unable to communicate their emotions because of impaired cognition, and the treatment they receive such as sedation, intubation, and mechanical ventilation.

Most patients in an ICU are unable to respond to existing validated anxiety measures. The Spielberger State - Trait Anxiety Inventory (STAI) which has 40 items and the Brief Symptom Inventory (BSI) which has 53 items are inappropriate for many ICU patients as they are too cognitively demanding.

The Faces Scale has been used for the self reporting of pain in children from 1990. The human face provides expressions for varied emotions such as happiness, sadness, anger, fear etc. Fear and anxiety have the same physical manifestation but different causes. Fear is the response to a danger that is actually present. Anxiety is a response to something perceived to be dangerous, perhaps on the basis of previous experience.

The Faces Anxiety Scale is a single item scale with five possible responses ranging from a neutral face to a face showing extreme fear and is scored from 1-5. In 2003 McKinley and co-workers developed and tested a 'Faces Anxiety Scale' for the assessment of anxiety in critically ill patients and proved it to be sensitive, reliable and easily understood and completed by patients receiving intensive care.

A prospective observational study was conducted to:

* assess the incidence and severity of anxiety experienced by patients in the ICU using the single item Faces Anxiety Scale.

* identify factors which contribute to the degree of anxiety and discomfort experienced by patients in the ICU.

Ethical clearance was obtained from the Hospital Ethics Committee.

Study Sample included patients admitted to the general ICU at SJGH who at the time of assessment could interact event intermittently in order to respond to being questioned about their feelings, opened their eyes spontaneously or in response to hearing their name, or were awake, and had sufficient corrected vision to see the Faces Scale.

Patients were asked if they would like to take part in the study. Those who indicated consent verbally or with a nod were included in the study.

Patients were presented with a Faces Anxiety Scale on an 11 x 42 cm card and asked to show the face that indicated how they felt at the time.

Responses verbal, nodding or shaking of the head or pointing to appropriate answer were recorded. Demographic, clinical and pharmacological data was obtained from the patients' charts. When the patients were discharged from the ICU to the ward, they were presented with a questionnaire by which their impressions of the ICU stay were assessed.

The topics covered were recognition of day/night pattern, sleep, unpleasant experiences, contact with relations, nursing care, and communication with doctors.

Results

A total of 100 patients were included in the study.

Sex 45 of these were male and 55 were female patients.

Age distribution 15 - under 29 years, 53 - between 30-59 years and 32 - over 60 years.

67 patients were emergency admissions, while 33 were planned admission.

Diagnostic category

35 admissions were post surgical, 25 cardiac, 18 obstetric, 9 respiratory, 6 hepato renal, 2 poisoning, 4 dengue haemorrhagic fever and 1 Guillain Barre.

Sedation

Fifty eight patients received sedation during their ICU stay.

Sixteen patients required ventilatory support during some period of their ICU stay while in the balance 84, the breathing was spontaneous.

Light

Lighting is another source of environmental stress. Although in some units there are few light options provided, the options that do exist are not used effectively. Even when the patient care does not require bright lighting it is left on.

Ceiling lights are particularly disturbing to patients lying flat on their back. Glare is also irritating, especially to older patients. Sixty-one patient in our study stated that the lighting was too bright while the balance 39 said it was acceptable.

The unacceptably high noise levels, the bright lighting and the various treatments that are required in caring for the patient ie injections, setting up IV lines, physiotherapy, suctioning positioning etc. provides an endless source of disturbance to the patient. All these lead to alteration of Circadian Rhythms and sleep deprivation.

Isolation from familiar faces though visiting must necessarily be restricted in the ICU setting, loved ones should be allowed to visit the critically ill patient as they can provide emotional support and can contribute meaningfully to the healing process. All 100 patients in our study were satisfied with the contact with loved ones.

Isolation from environment

Florence Nightingale was among the first recorded practitioners in western health care who considered environmental elements and the means to manipulate then when contemplating patient care in her notes on nursing written in 1859 Florence Nightingale states that "what nursing has to do is to put the patient in the best condition for nature to act upon him".

She stated that the patients condition can be optimised by careful consideration of ventilation, noise, light and darkness. She proposed that by manipulation of these factors the nursing care received by the patient will have maximum beneficial effect.

Most ICUs are located close to the operating theatre, labour room or emergency treatment unit and do not provide a view of the outside world. The blank walls of an ICU gives the patient a feeling of being shut in a box. An ICU that provides a view would contribute to the patient's wellbeing.

Noise

Noise levels should be limited as much as possible. Unnecessary and loud conversations should be avoided particularly by the patient's bed side. Though many noisy activities take place in the critical care setting, and audible alarms are necessary for patient care these should be kept at a minimum.

This includes adjusting alarm limits on monitoring devices as the patients condition changes so that alarms are not triggered off unnecessarily.

When purchasing new equipment, the amount of noise it creates should be part of the evaluation. Industry is developing ways to transmit bedside alarms to digital vibrating pagers worn by the patients care giver. This innovation would allow bedside alarms to be turned down without compromising patient's safety.