Actionable processes of care important to patients and family who experienced a prolonged intensive care unit stay: Qualitative interview study.

Aim: To use positive deviance to identify actionable processes of care that may improve outcomes and experience from the perspectives of prolonged intensive care unit (ICU) stay survivors and family members.

Design: Prospective qualitative interview study in two geographically distant settings: Canada (2018/19) and the United Kingdom (2019/20).

Methods: Patient and family participant inclusion criteria comprised: aged over 18 years, ICU stay in last 2 years of over 7 days, able to recall ICU stay and provided informed consent. We conducted semi-structured in-person or telephone interviews. Data were analysed using a positive deviance approach.

Results: We recruited 29 participants (15 Canadian; 14 UK). Of these, 11 were survivors of prolonged ICU stay and 18 family members. We identified 22 actionable processes (16 common to Canadian and UK participants, 4 Canadian only and 2 UK only). We grouped processes under three themes: physical and functional recovery (nine processes), patient psychological well-being (seven processes) and family relations (six processes). Most commonly identified physical/functional processes were regular physiotherapy, and fundamental hygiene and elimination care. For patient psychological well-being: normalizing the environment and routines, and alleviating boredom and loneliness. For family relations: proactive communication, flexible family visiting and presence with facilities for family. Our positive deviance analysis approach revealed that incorporation of these actionable processes into clinical practice was the exception as opposed to the norm perceived driven by individual acts of kindness and empathy as opposed to standardized processes.

Conclusion: Actionable processes of care important to prolonged ICU stay survivors and family members differ from those frequently used in ICU quality improvement (QI) tools.

Impact: Our study emphasizes the need to develop QI tools that standardize delivery of actionable processes important to patients and families experiencing a prolonged ICU stay. As the largest healthcare professional group, nurses can play an essential role in leading this.