ICU Diaries: A Useful Tool in the Reduction of Psychiatric Symptoms After Critical Illness*

Dear Diary. These words have been used at the beginning of many diary entries related to topics about weather, social events, economic, social, and health-related information … whatever the diarist wished to write about. “The desire to record details of our lives is as old as handwriting itself” (1). According to the Encyclopedia Britannica, personal diaries began during the Renaissance years (2). Ladies of the royal Japanese court wrote the first diaries of a consistently introspective nature in the 10th century. These records took the form of pillow books, so called because they were tucked in or under a pillow (3)

In more recent times, health diaries have become an important tool for both patient and provider in the management of personal health and wellness (4). A personal health journal, or health diary, is a record of your overall health and wellness. It is a journal you write yourself to help keep track of various aspects of your health (5). A 2017 study by Park et al (6) found that symptom diary use improved survival for patients with heart failure. The findings suggested that greater self-care behaviors, such as the use of a symptom diary, were associated with better heart failure outcomes. The results suggest that this type of diary (either in written or electronic format) is an excellent way to ensure proper treatment administration, indicated by both the high user acceptability scores and high treatment adherence. Furthermore, the diary may also be valuable for frequent and reliable monitoring of patient-reported outcomes in daily clinical practice. Another recent study showed positive results with the use of an electronic health e-diary, which helped to “ensure proper treatment administration, indicated by both the high user acceptability scores and high treatment adherence” (7).

In the same way, health diaries help personal awareness of personal health-related issues and ICU diaries help patients with potential post-ICU distress symptoms. The use of ICU diaries started in the 1980s in Denmark as a patient debriefing tool for in ICU patients after discharge (8). Since that time, ICU diaries are commonly used as a way to communicate with ICU patients and family members about ongoing progress and issues with patient care and condition status.

In this issue of Critical Care Medicine, Brandao Barreto et al (9) provide evidence that health diaries, used with patients who have been in an ICU for more than 24 hours and who were on mechanical ventilation, may show positive health benefits in the prevention of psychiatric symptoms after critical illness. The article (9) “Using qualitative synthesis to explore heterogeneity of randomized trials on ICU diaries” discusses the authors’ review of five qualitative studies of ICU patients under mechanical ventilation from which eight patients, called random controlled trial by the authors, were reviewed for their study ICU diary data. The overall aim of the study by Brandao Barreto et al (9) was to identify the various components of the ICU diaries that were associated in the reduction of psychologic symptoms after critical illness.

These diaries were written by the ICU staff and family members and were open ended as to what information would be entered. Entries might include pictures and factual accounts of what was going on with the patient medically or interactively with staff and family members while the patient was sedated and on the ventilator. The overall goal of the diaries was to “provide patients with a factual account of the ICU stay, in order to fill in memory aps, promoting a better understanding of he critical illness they survived” (9). The authors note that ICU-related posttraumatic stress disorder (PTSD) is associated with delusional memories by the patient and the use of a factual diary will reassure patients and reduce possible associated PTSD. The diaries were written by ICU staff and given to the patient after discharge from ICU, read together by patient, family, and healthcare professionals. In addition, after 3 days of being off the ventilator, the patients along with family members were allowed to write in the diary. The authors found that the presence of photographs in the diaries was positive for the patient and family members and was also effective in preventing psychologic symptoms post ICU.

Several recent studies by the same authors show similar positive therapeutic outcomes of ICU diaries. The 2019 study by Barreto et al (10) is important to the literature on ICU diaries and continues to show that such diaries are important to the psychologic well-being of patients who experience intubation in the ICU setting as a way of reducing the risks of depression and also in preserving the quality of life of patients after ICU admission. A follow-up study by the same authors in 2021 not only concluded positive impressions by patients, family, and staff members related to the use of ICU diaries but also noted that time pressure of ICU staff members writing in diaries may be an overall obstacle for staff diary entries (Barreto et al [11]). Both articles cited above as well as that of Brandao Barreto et al (9) show positive patient and family outcomes with the use of ICU diaries for patients on ventilators. All three studies used existing data from online databases such as PubMed, MEDLINE, OVID, Embase, and EBSCOhost. In the 2019 study (10), 12 of 787 studies were included in this meta-analysis research final data analysis, in the 2021 study (11), 28 studies were analyzed in a qualitative synthesis analysis, and in the current study by Brandao Barreto et al (9), eight randomized controlled trials of the ICU diary were included in the study analysis.

What is most useful from the study by Brandao Barreto et al (9) is the critique the authors give for ongoing use and evaluation of ICU diaries in general and suggestions on how to improve the data from the diary information. Quality improvement suggestions include the need for standardizing the ICU diary process, which would allow for comparison studies on this topic for generalizability as well as for variant differences. The authors also note that keeping up with diary entries use the human resource of nurses to facilitate the diaries, make entrees, and take photographs, all of which would need to be enumerated by institutions related to nurse work load expectations and perhaps financial support for the diary process. A third concern articulated by the authors is related to a need for diary follow-up appointments with patient and family members as a way of evaluating the general diary process as well as to assess more formally the overall experience outcomes of the diary process with patient and family. Such follow-up appointments should be reviewed with patient and family at discharge, so patient and family bring the diary with them for review and discussion. These follow-up diary discussions would be an interesting research project.

2. Brittanica: Diary. Available at: https://www.britannica.com/art/diary-literature. Accessed June 26, 2022 3. Epica: The Astonishing History of Journaling. 2018. Available at: https://epica.com/blogs/articles-by-epica/the-astonishing-history-of-journaling. Accessed June 30, 2022 4. Verbrugge LM: Health diaries. Med Care. 1980; 18:73–95 5. Freer CB: Health diaries: A method of collecting health information. J R Coll Gen Pract. 1980; 30:279–282 6. Park L, Dracup K, Shooley M, et al.: Symptom diary use and improved survival for pageants with heart failure. 2017 7. Rijsbergen M, Niemeyer-van der Kolk T, R Rijneveld R, et al.: Mobile e-diary application facilitates the monitoring of patient-reported outcomes and a high treatment adherence for clinical trials in dermatology. J Eur Acad Dermatol Venereol 2020; 34:633–639 8. Tripathy S, Acharya SP, Sahoo AK, et al.: Intensive care unit (ICU) diaries and the experiences of patients’ families: A grounded theory approach in a lower middle-income country (LMIC). J Patient Rep Outcomes 2020; 4:63 9. Brandao Barreto B, Luz M, Gusmao-Flores D: Using Qualitative Synthesis to Explore Heterogeneity of Randomized Trials on ICU Diaries. Crit Care Med 2022; 50:1654–1661 10. Barreto BB, Luz M, Rios MNO, et al.: The impact of intensive care unit diaries on patients’ and relatives’ outcomes: A systematic review and meta-analysis. Crit Care. 2019; 23:411 11. Barreto BB, Luz M, do Amaral Lopes SAV, et al.: Exploring family members’ and health care professionals’ perceptions on ICU diaries: A systematic review and qualitative data synthesis. Intensive Care Med. 2021; 47:737–749

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