Multi-perspectives of agitation and its management in the adult critical care environment.

Abstract

Background: Acute episodes of agitation are frequently experienced by patients during critical illness. Agitation is distressing for the patient and their family whilst the management of agitation can also be challenging for the clinical team. Aim and objectives: The aim was to capture the patient, the family, and the multidisciplinary team’s experiences and perspectives of agitation and its management in the Adult Critical Care environment (ACC). Objectives: i) critically review the evidence relating to the management of agitation in ACC (Phase1); ii) describe current strategies employed to manage patient agitation within ACC and identify associated risks and benefits (Phases 2 and 3); iii) understand the multidisciplinary team experiences and perspectives on agitation and its management (Phases 2 and 3); iv) critically review the evidence relating to the patients’ and their family’s experience of agitation during an ACC admission (Phase four); v) and explore patients’ and their family’s perspectives on agitation and its management (Phase five); vi) synthesis of the experiences and perspectives to provide an integrated picture of agitation and its management (Phase six). Methods: A multiphase study was undertaken to address each objective: i) an integrative review and narrative synthesis; ii) cross-sectional survey; iii) qualitative focus group or interview; iv) qualitative meta-synthesis; v) qualitative interview study and vi) triangulation of the study data. Results: Phase one: A total of 24 studies included in the review. Agitation identified as being associated with high-risk events. There was repeated uncertainty about the role of physical restraint in the development of agitation and its effective management. Phase two: The online survey produced 163 valid completions for analysis. Most respondents (98.5%) acknowledged the increased risk of harm in the presence of agitation and 76.3% felt that the management of agitated patients could be improved. Many participants felt equipped in the recognition of agitation but did not feel they had the knowledge to support decision-making around acute agitation management. Concern expressed regarding the use of physical restraint. Phase three: A total of 19 clinicians participated across two groups and seven one-to-one interviews. Physical restraint described as a recognised measure to control a person's movement, purposefully stopping them from causing harm to themselves or others. Three themes emerged: the burden of care, continuity of clinical decisionmaking, and the uncertainty and indecision. Phase four: Eight studies included in the review capturing 494 patients aged between were 18 and 92 years and 225 (45%) women. The analysis generated three core themes: (1) What is real, what is not, (2) Loss of communication and dependency, and (3) What helps, what does not. Phase five: A total of 13 participants were recruited and interviewed. Patient participants (n = 7) had a mean age of 65 years (± 13.39 years), 4 were male with the mean ACC length of stay was 59 days (± 70.88 days). Significant other participants (n = 6) all opted to be interviewed with the patient present. Three themes emerged: 1) The recollection of sensations and delusions: during agitation patient participants recalled agitation stemmed from vivid delusions with fragmented or incomplete information about their admission. 2) Communication and its impact: this encompassed the participant's views and experiences of communication both during a period of agitation and sometimes as a precursor to development. 3) Managing agitation, what helped and what did not. Phase six: Synthesised themes generated via triangulation producing the final recommendations: Facilitation and promotion of patient-centered visitation, prepare for agitation, and promotion of a communication strategy. A reconceptualise model to support and explore decision making offered. Conclusion: Planning for the development of agitation in all situations is vital. Clinical teams need to ensure families are encouraged to be actively involved in supporting care. Discord within teams and how this impacts care requires further exploration.

Date of Award	31 Aug 2021
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Paul Dark (Supervisor) & Janelle Yorke (Supervisor)