Critical illness rehabilitation: slide set

Rehabilitation after critical illness

Implementing NICE guidance

2009

NICE clinical guideline 83

What this presentation covers

Background

Scope

Definitions

Recommendations

Discussion

Find out more

Background

• Approximately 110,000 people are admitted into critical care units in England and Wales each year

• Most patients surviving critical illness have significant physical and non-physical morbidity and undergo a lengthy convalescence

• This morbidity is frequently unrecognised and, if identified, may not be appropriately assessed or managed

Scope

The recommendations are for adults with physical and non-physical rehabilitation needs as a result of a period of critical illness

Definitions

Physical morbidity

Problems such as muscle loss, muscle weakness, musculoskeletal problems including contractures, respiratory problems, sensory problems, pain, and swallowing and communication problems

Non physical morbidity

Psychological, emotional and psychiatric problems, and cognitive dysfunction

Clinical assessments

Short : brief assessment to identify patients who may be at risk of developing physical and non-physical morbidity

Comprehensive: more detailed assessment to determine the rehabilitation needs of patients who have been identified as being at risk of developing physical and non-physical morbidity

Functional: to examine the patient’s daily functional ability

Recommendations The recommendations cover the following areas:

Information

Information

Healthcare professional(s) with the appropriate competencies should coordinate the patient’s rehabilitation care pathway. As well as providing information and support, they should:

• ensure that rehabilitation goals are regularly reviewed and updated

• ensure delivery of structured and supported rehabilitation when applicable

• liaise with other relevant settings 2–3 months after discharge

Key principle of care

• Perform a short clinical assessment to determine the patient’s risk of developing physical and non-physical morbidity

• Perform a comprehensive assessment to identify current rehabilitation needs and to agree short-term and medium-term rehabilitation goals for patients at risk

• Start rehabilitation as early as clinically possible for patients at risk

During the critical care stay

• Perform a short clinical assessment for patients previously identified as being at low risk

• Perform a comprehensive clinical reassessment for patients at risk to identify rehabilitation needs and to agree or review and update rehabilitation goals

Before discharge fromcritical care

• Perform a short clinical assessment for patients previously identified as being at low risk before discharge from critical care

• Perform a comprehensive clinical reassessment for patients at risk

• Provide an individualised, structured rehabilitation programme for patients at risk

During ward-based care

• Perform a functional assessment of physical and non-physical dimensions

• Ensure that arrangements are in place, if continuing rehabilitation needs are identified before the patient is discharged, including appropriate referrals for ongoing care

Before discharge to home or community care

• Review the patient and perform a functional assessment of their health and social care needs

• Refer the patient to the appropriate rehabilitation or specialist services if: - the patient is recovering at a slower rate than

anticipated- the patient has developed unanticipated morbidity that

was not previously identified

2–3 months after discharge from critical care

Information and supportStage of care Information to cover

Critical care Illness, treatment and equipment used, possible rehabilitation needs

At discharge from critical care

Rehabilitation pathway, differences to expect in care such as environment, staffing and monitoring. Transfer of responsibility and handover of care, possible rehab needs and if applicable other problems such as sleeping, nightmares and adjusting to ward

At discharge to home/community care

Expected recovery, diet and other continuing treatments, managing daily living including driving, returning to work, benefits where applicable, statutory and non-statutory support services, and general guidance for the family and/or carer

Potential costs per 100,000 population

Description Costs (£ per year)

Physiotherapists – critical care early intervention 19,460

Clinical Psychologists – hospital and follow -up services 14,759

Physiotherapists – community follow -up services 18,658

Other therapists, e.g., dietetics, speech and language 3,629

Estimated cost of implementation 56,506

Potential benefits per 100,000 population

Description

Resources released(£ per year)

Reduced length of stay on general wards as a result of early intervention 3,321

Reduced length of critical care stay as a result of early intervention 26,532

Estimated total benefits from implementation 29,853

Discussion

• At what stage do we assess rehabilitation needs?

• How do we currently coordinate the rehabilitation of patients during and after critical illness?

• How can we ensure adequate provision of a multidisciplinary team to deliver rehabilitation services?

• What is the current provision of community-based rehabilitation services and do we need to improve this?

Find out more

Visit www.nice.org.uk/CG83 for:

•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing report and template•audit support•discharge checklist•joint position statement