OBJECTIVE OR RESEARCH QUESTION

To assess the effect of a diary versus no diary on patients, and their caregivers or families, during the patient's recovery process from admission to an intensive care unit (ICU).

NURSING IMPLICATIONS

During a patient's admission to the ICU, they can experience extreme physical and psychological stressors. These experiences impact on their recovery from critical illness and may result in both physical and psychological disorders. One strategy that has been developed and implemented by clinical staff to treat the psychological distress prevalent in ICU survivors is the use of patient diaries. These provide a background to the cause of the patient's ICU admission and an ongoing narrative outlining day-to-day activities.

Approximately 20 million patients require treatment in ICUs worldwide. The combined after-effects of critical illness and the ICU experience have been linked to both short- and long-term psychological compromise. These can have a significant impact on the patient's psychological and physical recovery. Therefore, patient diaries have been developed in an effort to address physical and psychological function, as well as consider the long-term implications on the patient and their families.

STUDY CHARACTERISTICS

The intervention under investigation was to review patient diaries that had been provided by ICU staff intended to assess their role in treating psychological distress in ICU survivors. The review included any randomized controlled trials or controlled clinical trials in which the presence or absence of patient diaries was the only difference between treatment groups. For the purpose of this review, patient diaries were defined as a prospectively written collection of events that occurred during the ICU stay, authored by staff or relatives, or both. Some of the primary outcomes looked at the risk of posttraumatic stress disorder, risk of anxiety, and the risk of depression.

The review identified 3 eligible studies: 2 describing ICU patients (N = 358) and one describing relatives of ICU patients (N = 30).1 The study involving relatives of ICU patients was a substudy of family members from one of the ICU patient studies. There was a mixed risk of bias within the included studies. Blinding of participants to allocation was not possible, and blinding of the outcome assessment was not adequately achieved or reported.

SUMMARY OF KEY EVIDENCE

Overall, the quality of the evidence was low to very low. The patient diary intervention was not identical between studies. However, each provided a prospectively prepared, day-to-day description of the participants' ICU admission.

No study adequately reported on risk of posttraumatic stress disorder as described using a clinical interview, family or caregiver anxiety or depression, health-related quality of life, or costs. Within a single study, there was no clear evidence of a difference in risk for developing anxiety (risk ratio [RR], 0.29; 95% confidence interval [CI], 0.07-1.19) or depression RR, 0.38; 95% CI, 0.12-1.19) in participants who received ICU diaries, in comparison to those who did not receive a patient diary. However, the results were imprecise and consistent with benefit in either group, or no difference. Within a single study, there was no evidence of difference in median posttraumatic stress symptom scores (diaries: 24 [SD, 11.6]; no diary: 24 [SD, 11.6]) and delusional ICU memory recall (RR, 1.04; 95% CI, 0.84-1.28) between the patients recovering from ICU admission who received patient diaries and those who did not. One study reported reduced posttraumatic stress symptoms in family members of patients recovering from admission to ICU who received patient diaries (median, 19 [range, 14-28]), in comparison to no diary (median, 28 [range, 14-38]).

Currently, there is minimal evidence from randomized controlled trials of the benefits or harms of patient diaries for patients and their caregivers or family members. A small study has described their potential to reduce posttraumatic stress symptoms in family members. However, there is currently inadequate evidence to support their effectiveness in improving psychological recovery after critical illness for patients and their family members.

BEST PRACTICE RECOMMENDATIONS

Posttraumatic stress disorder is becoming widely acknowledged as being a recognized condition following admission to ICU.

* The introduction of patients' diaries has long been held to aid in addressing the psychological impact of ICU admissions. Yet the evidence currently failed to evaluate effectively the use of the diaries in promoting patient recovery. The review even questioned the safety of the administration of the diaries with regard to the adverse effect these may have on the patient.

* Further research is needed to address both the use of the diaries with regard to the complexity of their use and their delivery.

Reference