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Clinicians' evaluation and management of mental health, substance abuse, and chronic pain conditions in the intensive care unit*

Broyles, Lauren M. BSN, BA, RN; Colbert, Alison M. MSN, RN; Tate, Judith A. MSN, RN; Swigart, Valerie A. PhD, RN; Happ, Mary Beth PhD, RN

doi: 10.1097/01.CCM.0000292010.11345.24
Clinical Investigations

Objective: 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.

Design: Longitudinal qualitative description.

Setting: Intensive care unit of an urban academic medical center.

Patients: Total of 12 patients with co-existing MHSA or CP conditions who were weaning from mechanical ventilation.

Interventions: Intensive care unit clinicians, patients, and family members were formally interviewed and directly observed in the critical care setting for 56 consecutive weeks.

Measurements and Main Results: 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.

Conclusions: 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.

From the Departments of Acute and Tertiary Care (LMB, JAT, MBH) and Health Promotion and Development (AMC, VAS), School of Nursing, University of Pittsburgh, Pittsburgh, PA.

The authors have not disclosed any potential conflicts of interest.

Supported, in part, by the 2005 Mentorship Grant from the American Association of Critical-Care Nurses, Aliso Viejo, CA, and by research grants R01-NR07973 and F31-NR008822 from the National Institute of Nursing Research, National Institutes of Health.

Presented, in part, at the American Thoracic Society International Conference, San Diego, CA, May 22, 2006.

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© 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins