Broyles Lauren M, Colbert Alison M, Tate Judith A, Swigart Valerie A, Happ Mary Beth
Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
Crit Care Med. 2008 Jan;36(1):87-93. doi: 10.1097/01.CCM.0000292010.11345.24.
The purpose of this study was to describe clinicians' evaluation and management of co-existing mental health, substance abuse (MHSA), and chronic pain (CP) conditions in patients with prolonged critical illness. Little is known about the evaluation and management of these conditions in the intensive care unit, and practice guidelines do not address management in the context of critical illness, optimal sedation/analgesia, or ventilator weaning.
Longitudinal qualitative description.
Intensive care unit of an urban academic medical center.
Total of 12 patients with co-existing MHSA or CP conditions who were weaning from mechanical ventilation.
Intensive care unit clinicians, patients, and family members were formally interviewed and directly observed in the critical care setting for 56 consecutive weeks.
Transcribed interviews, field notes, and clinical records, representing >400 documents, were reviewed and coded using constant comparative analysis to identify the facilitators, barriers, contextual factors, and consequences associated with the evaluation and management of MHSA and CP conditions. Numeric clinical data supplemented and clarified thematic findings. Facilitators of MHSA and CP evaluation and management included family as history keepers, the use of subspecialty consultations, and anticipated alcohol withdrawal. Barriers included limited history taking and assessment of MHSA and CP conditions and the use of cognitive shortcuts. Consequences included nonintegration of MHSA and CP medications and diagnoses, episodic pharmacologic responses to psychobehavioral symptoms, and clinician-patient interpersonal tension. Contextual factors involved ambiguous psychobehavioral symptomatology, patients' critical illness and inability to speak, and competing clinical goals.
The explicit evaluation and management of MHSA and CP conditions was highly variable and inconsistent across cases. Findings suggest that MHSA and CP conditions require monitoring and management similar to that required for other chronic conditions. Multidisciplinary, individual-level, and system-level responses are warranted to address the complex interplay of barriers, consequences, and context.
本研究旨在描述临床医生对危重病延长患者并存的心理健康、药物滥用（MHSA）和慢性疼痛（CP）状况的评估与管理。对于重症监护病房中这些状况的评估与管理知之甚少，且实践指南未涉及危重病、最佳镇静/镇痛或呼吸机撤机背景下的管理。
纵向定性描述。
城市学术医疗中心的重症监护病房。
共有12例并存MHSA或CP状况且正在撤机的患者。
对重症监护病房的临床医生、患者及其家属进行正式访谈，并在重症监护环境中连续56周进行直接观察。
对转录的访谈、现场记录和临床记录（超过400份文件）进行审查，并使用持续比较分析进行编码，以确定与MHSA和CP状况评估与管理相关的促进因素、障碍、背景因素及后果。数值临床数据补充并阐明了主题研究结果。MHSA和CP评估与管理的促进因素包括家属作为病史记录者、使用专科会诊以及预期的酒精戒断。障碍包括对MHSA和CP状况的病史采集和评估有限以及使用认知捷径。后果包括MHSA和CP药物及诊断未整合、对心理行为症状的间歇性药物反应以及医患人际紧张关系。背景因素涉及模糊的心理行为症状、患者的危重病及无法言语以及相互竞争的临床目标。
MHSA和CP状况的明确评估与管理在不同病例中差异很大且不一致。研究结果表明，MHSA和CP状况需要与其他慢性病一样进行监测和管理。有必要采取多学科、个体层面和系统层面的应对措施，以解决障碍、后果和背景之间复杂的相互作用。
