A Study to Assess the Post Traumatic Stress Symptoms (PTSS) and Anxiety Among Patients After Transfer Out from Intensive Care Unit at Shri Vinoba Bhave Civil Hospital

BACKGROUND: Critical illness can expose patients to traumatic stressors that are caused by both Intensive Care intervention techniques and life threatening experiences. For the last ten years, there has been an increasing interest and attention regarding psychological consequences related to surviving critical illness. This patient population were found to have both Post Traumatic Stress Symptoms and Anxiety. OBJECTIVE: To assess the Post Traumatic Stress Symptoms (PTSS) and Anxiety among patients after transfer out from the ICU, to correlate the relationship between PTSS and Anxiety and find the association between Post Traumatic Stress Symptoms and Anxiety with selected demographic and clinical variables METHODOLOGY: A time series design was adopted and 200 samples were selected by non-purposive sampling technique. Sociodemographic and clinical variables data was collected using the self-administered questionaries’ and PTSS was assessed by using Impact Event Scale Revised and Anxiety was assessed by Anxiety Assessment Scale once the patient is transfer from ICU.Follow up interview was done on 7, 14, 30 day. RESULT: The study findings suggest that Out of 200 samples (patients), 77% of patient were having moderate anxiety, 13% were having severe anxiety, 9.5% were having mild anxiety, & 0.5% were having no anxiety on 0 day. On day 30 62.5% were having moderate anxiety, 33.5% were having mild anxiety, 2% each were having severe and no anxiety So people in the moderate group reduced to 62% and an increment is found in the mild group percentage as 33.5%. On day 0, 51% were having moderate PTSS, 47.5% were having low PTSS and 3% were having high PTSS, none of the patient was having severe PTSS. On day 30, 97.5% were having low PTSS and 7.5% were having moderate PTSS, none of the patient was having high or severe PTSS. This shows a remarkable improvement on day 30 with 92.5% low PTSS. There is no correlation between PTSS and anxiety of patients on 0, 7, 14, 30 day. There was no association between demographic & clinical variables and PTSS & anxiety scores. CONCLUSION: Technological advancements in health care setting has reduce mortality rate of human beings but their emotional consequences also need to be conducted.


INTRODUCTION
More people worldwide becomes critically ill every year and require treatment in the Intensive Care Unit.Millions of patients survive critical illness due to the improvements in medical research and technological advances in the Intensive Care Units.The emotional consequences of being critically ill has increased because of this change in survival rate.Critical illness can expose patients to traumatic stressors that are caused by both Intensive Care intervention techniques and life threatening experiences.For the last ten years, there has been an increasing interest and attention regarding psychological consequences related to surviving critical illness.This patient population were found to have both Post Traumatic Stress Symptoms and Post Traumatic Stress Disorders.Painful procedures, mechanical ventilation and significant physical limitations are some of the factors that makes the critically ill patients get expose to stressors.In addition, prolonged physical weakness, disturbances in sleep patterns, impaired memory, and attention and concentration deficit have also been reported among ICU survivors.Patients with Post Traumatic Stress Symptoms were found to have symptoms of PTSD, but they did not meet all the criteria for making the diagnosis of PTSD.

NEED OF THE STUDY
According to estimates, the lifetime prevalence of PTSS globally is 8% in the general population, with rates higher in females (10-12%) and lower in males (5-6%).Approximately 6% of women giving birth, 8%-45% of burn patients, and 20%-28% of cardiac patients possess PTSS-like symptoms, and the frequency of PTSS was documented from 17%-30% in intensive care units .Admitted to the intensive care unit exposes patients to severe stressors, including physical constraints, pain, lack of sleep, and communication difficulties.A number of demographic characteristics have been identified as risk factors for the development of PTSD, including younger age, gender, educational attainment, and past psychiatric history.It is been observed during the clinical exposure that ICU is an environment where patients face lifethreatening situations, undergo invasive medical procedures, and experience high level of stress.The intense nature of the ICU environment can contribute to the development of posttraumatic stress symptoms and anxiety in patients.Moreover ICU experiences can have long lasting effects on patient's mental health.Survivors of critical illness may suffer from psychological distress even after their physical health has improved.Understanding the prevalence of post-traumatic stress symptoms and anxiety in this population can help health care professionals provide appropriate support and interventions .Hence the investigator planned to conduct a study to assess the Post Traumatic Stress Symptoms and Anxiety of the patients after transfer from Intensive Care Unit.

OBJECTIVES:
The Objectives of the study are:-• To assess the Post Traumatic Stress Symptoms (PTSS) and Anxiety among patients after transfer out from the ICU.• To correlate the relationship between PTSS and Anxiety.
• To find the association between Post Traumatic Stress Symptoms and Anxiety with selected demographic and clinical variables.

HYPOTHESIS: RESEARCH HYPOTHESIS
H1:-There will be significant correlation between post-traumatic stress symptoms and anxiety among patients after discharge from the ICU at 0.05 level of significance.H2:-There will be significant association between post-traumatic stress symptoms and anxiety with selected demographical and clinical variables at 0.05 level of significance.

RESEARCH DESIGN / METHOD:-
The aim of the present study was to assess post-traumatic stress symptoms and anxiety among patients after transfer from ICU.Therefore, a Quantitative research approach was adopted.

TOOL
The following tools were used in order to obtain the data The IES-R has not been updated to match the DSM-5, so it does not include items to full assess negative alterations in cognition and mood, for instance.Respondents are asked to identify a specific stressful life event and then indicate how much they were distressed or bothered during the past seven days by each "difficulty" listed.Items are rated on a 5-point scale ranging from 0 ("not at all") to 4 ("extremely").The IES-R yields a total score (ranging from 0 to 88) and subscale scores can also be calculated for the Intrusion, Avoidance, and Hyperaurosal subscales.The scoring of the scale ranges from 0 = No symptoms 1 = Few symptoms 2 = Moderate symptoms 3 = A High Level of symptoms 4 = an extreme high level of symptoms

Section -D: -Anxiety Assessment Tool
It is the self-assessment tool which consist of the 7 questions modified from the Anxiety Assessment Short Form-a .Items are rated on 5 point rating scale ranging from 1 ( Never ) to 5 ( Always ) It yields a total score from ranging from 1-35 .thescoring of the tool is as follows Less than 15 -No Anxiety 15 -19 --Mild Anxiety 20 -27 -Moderate Anxiety 28 -35 ---Severe Anxiety

DATA COLLECTION PROCESS
The research will be In the ICU and before discharge from the hospital, the researcher will visit the patients, explained about the study, and completed consent procedures.On the day of transfer out from ICU anxiety of the patient will be assessed 2 hours prior to transfer to the step down wards using Anxiety Assessment Tool.Once patient is transfer out to the ward within 24 hours PTSS of the patient will be assessed using Impact Event Scale Revised.Follow up interviews (on day 14, 30) will be conducted over the telephone; however, some will be done when patients came for follow up to the hospital.The telephone interviews will be conducted at a suitable time for the patients; they were allowed to stop the call anytime and request a return call when they desire.

Table 1 Indicates the Frequency and Percentage Wise Distribution of Demographic Variables
The majority of the sample 150(75%) of them belongs to the age group between 26 and 50 years.Whereas, 12(6%) belongs to 18-25 years of and 75 and more years samples were 3(1.5%).151(75.5%)were male and female 49(24.5%).With respect of education, most of the samples 72 (36%) of them have completed primary /secondary education & 108(54%) has completed Higher secondary education.However, only 20 (10%) sample were graduate and above education level in this present study.In Marital status 166 (83%) of them were married /Living together.28(14%) of them were single and only 6 (3%) of them are widowed.Occupational status depicts that most of the sample 179(89.5%) of them were self-employed, 14(7%) of them were professional, whereas only 7(3.5%) of them unemployed in this study.Number of children shown , almost all 188(94%) of them had 1-2 children .11(5.5%) of them had no children during this study period .Regards history of substance abuse, 78(39%) of them had one habit of substance abuse i.e either smoking, alcohol and tobacco chewing .60(30%) of them had two substance abuse i.e smoking, alcohol and tobacco whereas 22 (11%) of them had all three habits of substance abuse i.e smoking, alcohol and tobacco.40(20%) of them had none of the substance abuse of smoking, alcohol and tobacco.Regards place of residence 118 (59%) of them are residence of U.T of Diu Daman & Dadra Nagar Haveli whereas 56(28%) of them belongs to Gujarat & 26(13%) of them were residence of Maharashtra in present study.

No association between attitude and IES -R scores
The above table 7 depicts that correlation between anxiety and Post Traumatic Stress Symptoms level among patients after transfer from Intensive Care Unit.The results shown, that there was no correlation found on day 1 st , 7 th , 14 th and 30 th day between anxiety and stress level Even though all the day correlation was negatively correlated which was not significant correlation (p>0.05) .It seems anxiety level decreased while stress level was improved.Hence, fail to reject the Null hypothesis H0 1 .Therefore, there was no correlation between anxiety and Post Traumatic Stress Symptoms level on day 0,7 th , 14th and 30 day.no 10 shows association between level of anxiety and demographic variables, results reveals that there was no association with demographic variables such as age (χ2 =5.04) , gender (χ2=2.06),education (χ2=5.25),marital status (χ2=2.25),Number of children (χ2=11.43), history of substance abuse(χ2=10.28),place of residence (χ2=3.45)which was not significant (p>0.05)except occupation (χ2=31.56,p<0.001).Therefore, Fail to reject the null hypothesis H0.Therefore, there was no association between anxiety and demographic variables except occupation.no 11 shows association between level of anxiety and clinical variables, results reveals that there was no association with clinical variables such as length of ICU (χ2 =9.85), Reason for ICU Admission (χ2=0.84),Previous history ICU admission (χ2=1.46)which was not significant (p>0.05)Therefore, Fail to reject the null hypothesis H02.Therefore, there was no association between anxiety level and clinical variables.

CONCLUSION
Based on the findings of the following study conclusion drawn: 1. Majority of patients suffer from Post-Traumatic Stress Symptoms and Anxiety after transfer from Intensive Care Unit to wards.2. There is no any correlation between Post Traumatic Stress Symptoms and Anxiety of the patients after transfer out from ICU. Technological advancements in health care setting has reduce mortality rate of human beings but their emotional consequences also need to be conducted.

Section - A
Demographic data It consist of age, gender, education, marital status, occupation, education, number of children, History of substance abuse, Place of residence Section -B -Clinical Variables It consist of diagnosis, Length of ICU stay, Reason for ICU Admission, Previous history of ICU admission.Section -C: Impact Event Scale -Revised (IES-R) The IES-R is a 22-item self-report measure (for DSM-IV) that assesses subjective distress caused by traumatic events.It is a revised version of the older version, the 15-item IES (Horowitz, Wilner, & Alvarez, 1979).The IES-R contains 7 additional items related to the Hyperaurosal symptoms of PTSD, which were not included in the original IES.Items correspond directly to 14 of the 17 DSM-IV symptoms of PTSD.

Table 2 : 7 . 1 .
Frequency and percentage wise distribution to assess the Post-traumatic Stress Symptoms (PTSS) and anxiety among patients after transfer from intensive care unit at Shri Vinoba Bhave civil hospital, according to their clinical data.( n History of substance abuse: Any one : Alcohol, Smoking, Tabaco Chewing Any two: Alcohol,Smoking,Tabacco chewing All three : Alcohol,Smoking,Tabacco chewing None of Length of the ICU Stay Section IV: Find out association between selected demographical & clinical variable with PTSS and anxiety scoresTable8: Association for level of level of PTSS s and selected demographic data.

Table 10 :
Association for level of anxiety with selected demographic data.

Table 11 :
Association of level of anxiety with selected clinical variables.

Table 1 : Frequency and percentage wise distribution to assess the post-traumatic stress symptoms (PTSS) and anxiety among patients after transfer from intensive care unit at Shri Vinoba Bhave Civil Hospital, according to their demographic data. (n = 200) Demographic variables Frequency Percentage 1.Age (in years):
Assessment of Post-Traumatic Stress Symptoms and Anxiety among patients after transfer from ICU Section III : Find out correlation between Post Traumatic Stress Symptoms & Anxiety among patients Section IV : Find out association between selected demographical & clinical variable with PTSS and anxiety scores .
: Section I -Description of Demographic & Clinical Variables Section II: Section I -Description of Demographic & Clinical Variables

Table 2 indicates clinical variables,
Regards Length of the ICU, Majority 154 (77%) of them has stayed 6-10 days.Around 19 samples, 19(9.5%) had stayed 1-5days and 17(8.5%) of them were stayed 11-15 days whereas 10(5%) of them stayed for more than 15 days.Regards reason for ICU Admission, 170(80%) of them admitted for medical and 30(15%) of them were admitted for post-operative.Regards previous history of ICU admission, most all 190 (95%) of them do not had any history of ICU Admission and only 10 (5%) had previous history of ICU admission.

II: Assessment of Post-Traumatic Stress Symptoms and Anxiety among patients after transfer from ICU Table-3: Frequency and percentage wise distribution of level of post-traumatic stress symptoms (PTSS) among patients after transfer from Intensive Care unit at Shri Vinoba Bhave Civil hospital
them were moderate level of stress.Only 2 (1%) sample was having high level stress.None of them were severe level.On 14 th day, majority 164 (82%) of them were in low level and 36(18%) of them were in moderate level of stress.None of them were having High and severe level of stress.On 30th day, majority 185 (92.5%) of them were in low level and 15 (7.5%) of them were having moderate level of stress.None of them were in High and severe level stress.

Table - 4: Frequency and percentage wise distribution of level of anxiety among patients after transfer from intensive care unit at Shri Vinoba Bhave Civil Hospital. (n = 200)
th day, majority 142 (71%) of them were in moderate level and 49(24.5%) of them were in mild level of anxiety, 6 (3%) samples in severe level of anxiety & Only 3 (1.5%)sample was in No anxiety level .On 30 th day , majority 125 (62.5%) of them were in moderate level and 67(33.5%) of them were having mild level of anxiety.Each 4 (2%) sample were having No anxiety level and severe anxiety level respectively.

Table 5
indicates that level of PTSS score among patients after transfer from intensive care unit , On Day 0 , the mean percentage & the Mean±SD of PTSS was 27%, 23.87±3.12,whereas,On Day 7, the mean percentage & the Mean±SD of PTSS score was 27% & 23.41±14.56.However, Day 14, the mean percentage and the Mean±SD of PTSS score was 24% & 21.05±3.12.On Day 30, the mean percentage was 23% whereas the Mean±SD of PTSS score were 19.93±3.06Hence, it can be interpreted that, Day by Day the PTSS score level gradually decreased among patients after transfer from intensive care unit in this present study. .From the results of 'F' value for stress score obtained as F = 13.84 which was found highly significant difference between the days of studies ['p' <0.001].It is shown in the study that improvement among subjects regarding stress, mean score of PTSS was high in the initial day 23.87& got reduced gradually and finally reached to 19.93.Therefore, there was highly significant differences on stress scores and between the days of studies.Hence Accept and retained Research hypothesis H1.

Table 6
indicates that that level of anxiety among patients after transfer from intensive care unit, on Day 1 , the mean percentage were 68% & the Mean±SD of anxiety score were 23.7±3.38.Whereas, on Day 7, the mean percentage and the Mean±SD of anxiety score were 63 % & 22.19±3.20.However, Day 14, the mean percentage was 60% and Mean±SD of anxiety score was 21.12±3.19.On Day 30, the mean percentage was 57% whereas the Mean±SD of anxiety score were 19.9±3.27.From the results of 'F' value for anxiety score was obtained as F = 502.15which was found highly significant difference between the days of studies ['p' <0.001].It shown in the study improvement among subjects regarding anxiety, mean score of anxiety which was high in the initial day 23.70 got reduced gradually and finally reached to 19.99.Hence, it can be interpreted that, Day by Day the anxiety level gradually decreased among patients after transfer from Intensive Care Unit .

Table no 9
shows association between level of Post Traumatic Stress Symptoms scores and clinical variables, results reveals that there was no association with clinical variables such as length of ICU (χ2 =6.28) , Reason for ICU Admission (χ2=0.238)which was not significant (p>0.05)except Previous history ICU admission (χ2=1.46,p=0.041) .Therefore, Fail to reject the null hypothesis H0.Therefore, there was no association between Post Traumatic Stress Symptoms and clinical variables except Previous history ICU admission