South East Coast Operational Delivery Networks Hosted by Medway Foundation Trust South East Coast Operational Delivery Network Background Critical Care Rehabilitation The optimisation of recovery from critical illness, rather than mere survival, has developed increasing prominence as the physical and psychological ramifications of a stay in critical care have become widely acknowledged. Research on the longer term consequences of critical illness has shown that significant numbers of patients surviving critical illness have important continuing problems. "For many, discharge from Critical Care is the start of an uncertain journey to recovery characterised by, among other problems, weakness, loss of energy and physical difficulties, anxiety, depression, post-traumatic stress (PTS) phenomena and, for some, a loss of mental faculty (termed cognitive function). Family members become informal care givers, and that itself can exert a secondary toll of ill-health; family relationships can become altered and financial security impaired." (NICE 2009) In response to a growing awareness, a number of hospitals established follow up clinics to both better understand what really happens to critical care survivors and to try to address their problems. Over time, a number of service delivery models have been developed. Whilst evidence suggests that multidisciplinary rehabilitation strategies after critical illness can aid physical recovery and help people cope with their physical and non-physical problems, the evidence base remains patchy and outcomes of specific interventions have yet to be proven. NICE Clinical Guideline 83 (2009) Recognition of the unmet clinical needs of patients surviving critical illness prompted the National Institute for Health and Care Excellence (NICE) to publish guidelines for rehabilitation. The recommendations within NICE GG83 are consensus based due to the lack of hard evidence that then existed on the outcomes of specific models of rehabilitation. NICE CG83 refrains from prescribing a set model but does outline the expectation that: all patients admitted to critical care should be assessed to determine their risk of developing ongoing physical or non-physical morbidity 1 of 19
all patients deemed at risk should have a comprehensive assessment to identify their individual rehabilitation needs rehabilitation strategies are to be commenced as early as possible and continue throughout the entire recovery pathway; commencing in critical care, continuing throughout transfer to the ward and following discharge home the service should be multi-disciplinary and be provided by staff with an understanding of critical care and who understand the context of the patients' clinical stories the patients and their families must be involved and informed at all stages of the pathway the initiation of audit and research is required to inform the debate about best service delivery models To facilitate audit of service delivery NICE has produced a patient rehabilitation prescription document that can track interventions throughout the pathway of care. For a more detailed assessment of the implementation of rehabilitation NICE has developed an Audit Support tool. Both audit tools can be found at the end of this summary document. Despite the publication of NICE CG83 and the associated recommendations, clinical implementation of the guidelines has proved challenging for many Trusts. The barriers often cited being a lack of resource, both finance and staff. Whilst the need for critical illness rehabilitation is now little disputed by critical care staff, recognition of the problem is less well understood by clinical colleagues in primary care and commissioning bodies. South East Coast Operational Delivery Network Securing the resource to fulfil the recommendations remains a challenge for many Trusts, those within South East Coast being no exception. Many Trusts have been very proactive in developing rehabilitation pathway documents and delivering rehabilitation to their patients despite no identified budget for the additional work generated. The commitment of the Operational Delivery Network is to: engage with critical care service providers across the region recognise current rehabilitation strategies share best practice support the development of pathways of care support the instigation of care pathways by Trusts where the service is less well developed engage with Critical Care Commissioners liaise with primary care providers of rehabilitation for other patient groups scope and understand service delivery across the region assist with audit and analysis of outcome data 2 of 19
Nationally, the expectation of NHS England is that all Trusts are able to demonstrate that all patients receive a short clinical assessment within 24 hours of admission to Critical Care and that those patients identified as at risk of on-going physical or nonphysical morbidity receive a rehabilitation prescription or pathway of care. These standards have been adopted by the SEC ODN and form part of the work programme. It is the expectation that Critical Care Units within the ODN will: participate in Critical Care rehabilitation forums develop and instigate pathways of care share best practice participate in audit of rehabilitation service delivery engage with SEC ODN and local commissioning groups Critical Care rehabilitation forums will continue in Kent & Medway; Surrey and Sussex with overarching co-ordination by the SEC ODN. Standards and practice initiatives discussed in each forum will be shared with rehabilitation, clinical and nursing leads. Produced by Caroline Wilson, Deputy Network Manager, South East Coast ODN. August 2014. 3 of 19
Attachments (Double click on attachment 1 to open complete document). 4 of 19
Critical illness rehabilitation Audit support Implementing NICE guidance 2009 5 of 19
This audit support accompanies the clinical guideline: Rehabilitation after critical illness (available online at www.nice.org.uk/cg083). Issue date: 2009 This is a support tool for clinical audit based on the NICE guidance. It is not NICE guidance. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. National Institute for Health and Clinical Excellence MidCity Place, 71 High Holborn, London WC1V 6NA; www.nice.org.uk National Institute for Health and Clinical Excellence, 2009. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of the Institute. 6 of 19
Using audit support The audit support document can be used to measure current practice in critical illness rehabilitation against the recommendations in the NICE guideline. Use it for a local audit project, by either using the whole tool or cutting and pasting the relevant parts into a local audit template. NICE has produced a checklist for healthcare professionals coordinating the patient s rehabilitation care pathway, which if used by trusts will significantly help with the process of auditing. Available from www.nice.org.uk/cg83 Audit criteria and standards are based on the guideline s recommendations. The standards given are typically 100% or 0%. If these are not achievable in the short term, set a more realistic standard based on discussions with local clinicians. However, the standards given remain the ultimate objective. The data collection tool can be used or adapted for the data collection part of the clinical audit cycle by the trust, service or practice. The tool is based on the guideline s recommendations relating to clinical activity. Data may be required from a range of sources, including policy documents and patient records. Suggestions for these are indicated on the tools, although this is not an exhaustive list and they may differ in your organisation. The sample for this audit should comprise those patients discharged from an episode in critical care. Select an appropriate sample in line with your local clinical audit strategy. Whether or not the audit results meet the standard, re-auditing is a key part of the audit cycle. If your first data collection shows room for improvement, rerun it once changes to the service have had time to make an impact. Continue with this process until the results of the audit meet the standards. Links with other national priorities The audit based on this guideline should be considered in conjunction with other national priorities such as: Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital (2007). Available from www.nice.org.uk/cg50 Intensive Care National Audit and Research Centre (ICNARC) 7 of 19
Clinical criteria for Critical illness rehabilitation Key Principle of Care Criterion 1 The percentage of patients who had a named healthcare professional identified, with the appropriate competencies, to coordinate their rehabilitation care pathway. The healthcare professional(s) may be intensive care professional(s) or, depending on local arrangements, any appropriately trained healthcare professional(s) from a service (including specialist Rehabilitation Medicine services) with access to referral pathways and medical support (if not medically qualified) Critical care stay Criterion 2 Percentage of patients who had a short clinical assessment performed to determine their risk of developing physical and non-physical morbidity. Criterion 3 See appendix. Percentage of patients identified as at risk of physical and non-physical morbidity who had a comprehensive clinical assessment performed to identify their current rehabilitation needs. Criterion 4 See appendix. Percentage of patients identified as at risk who had short-term and medium-term rehabilitation goals set, based on the comprehensive clinical assessment, that included an individual structured rehabilitation programme. During the critical care stay, the patient may not gain full consciousness or may not have full capacity to give formal consent. Therefore, the involvement of the family and/or carer is important at this stage. Also see appendix. 8 of 19
Criterion 5 Percentage of patients and family (or carers) who received the following information during their critical care stay: Information about the critical illness, interventions and treatments. Information about the equipment used during their critical care stay. If applicable, information about any possible short-term and/or long-term physical and non-physical problems which may require rehabilitation. A Patients who are unable to receive this information due to their physical/mental status, e.g. if they are not fully conscious or do not have full capacity to give consent. B Patients who do not consent to this information being given to their family and/or carer. Before discharge from critical care Criterion 6 For those patients previously identified as at low risk, percentage who had a short clinical assessment before their discharge from critical care to determine their risk of developing physical and non-physical morbidity. Criterion 7a See appendix. For those patients previously identified as at risk, percentage who had a comprehensive clinical reassessment to identify their current rehabilitation needs. Criterion 7b See appendix. For those patients identified as at risk, percentage who had their rehabilitation goals agreed or reviewed and updated based on the comprehensive clinical reassessment. The family and/or carer should also be involved, unless the patient disagrees. Also see appendix. 9 of 19
Criterion 8 The percentage of patients who received the following information before or as soon as possible after their discharge from critical care: Information about the rehabilitation pathway Information about the differences between critical care and wardbased care. Information about the transfer of clinical responsibility to a different medical team. A Patients who are unable to receive this information due to their physical/mental status, e.g. if they are not fully conscious or do not have full capacity to give consent. Criterion 9 The information should be given to the patient s family and/or carer if the patient agrees. Percentage of patients identified as at risk who were given the contact details of the healthcare professional(s) coordinating their rehabilitation care pathway, on discharge from critical care. During ward-based care Criterion 10 For those patients previously identified as at low risk before discharge from critical care, percentage who had a short clinical assessment to determine the risk of physical and non-physical morbidity. Criterion 11 See appendix. For those patients identified as at risk, percentage who had a comprehensive clinical reassessment to identify their current rehabilitation needs. See appendix. 10 of 19
Criterion 12 For those patients identified as at risk, percentage who were offered an individualised, structured rehabilitation programme, based on the comprehensive clinical reassessment and the agreed or updated rehabilitation goals set before the patient was discharged from critical care. See appendix. Before discharge to home or community care Criterion 13 For those patients receiving the individualised structured rehabilitation programme during ward-based care, percentage who before discharge had a functional assessment performed. Criterion 14 See appendix. Percentage of patients identified as at risk who were given the contact details of the healthcare professional(s) coordinating their rehabilitation care pathway, on discharge from hospital. Criterion 15 Percentage of patients who received the following information before their discharge to home or community care: Information about their physical recovery. If applicable, information about diet and any other continuing treatments. Information about how to manage activities of daily living. General guidance, especially for the family and/or carer, on what to expect and how to support the patient at home. This should take into account both the patient s needs and the family s/carer s needs. Give the patient their own copy of the critical care discharge summary. The information should be given to the patient s family and/or carer if the patient agrees. 2 3 months after discharge from critical care 11 of 19
Criterion 16 Percentage of patients with rehabilitation needs who had a review 2 3 months after discharge from critical care. 12 of 19
Patient data collection tool for Critical illness rehabilitation Complete one form for each patient or episode. Patient identifier: Sex: Age: Ethnicity: Critical care admission data 1 Date and time of admission: / / : hrs 2 Primary reason for admission: Planned local medical Planned local surgical Unplanned local medical/surgical Planned transfer in Unplanned transfer in Repatriation Comments: 3 Location prior to admission: No. Data item no. Criteria Yes No During the critical care stay 1 1.1 Did the patient have a named healthcare professional to coordinate their rehabilitation care pathway? 1.2 If Yes ; What was the profession of this person: 1.3 Does this person have the appropriate competencies to coordinate the rehabilitation care pathway? 2 2.1 Did the patient have a short clinical assessment to determine their risk of developing physical and nonphysical morbidity? NA/ a NICE guideline ref. 1.1.1 1.1.2 2.2 If Yes ; What risk(s) were identified? Physical: Unable to get out of bed independently Anticipated long duration of critical care stay Obvious significant physical or neurological injury Lack of cognitive functioning to continue exercise independently Unable to self ventilate on 35% O 2 or less Presence of premorbid respiratory or mobility problems Unable to mobilise independently over short distances Other(s): (state) 13 of 19
No. Data item no. Criteria Yes No NA/ a NICE guideline ref. 2.3 Non-physical: Recurrent nightmares Intrusive memories of traumatic events which occurred prior to admission New and recurrent anxiety or panic attacks Expressing a wish not to talk about their illness or changing the subject quickly Other(s): (state) 2.4 Date and time of this assessment: / / : hrs For those patients identified as at risk of physical and non-physical morbidity: 3 3.1 Was a comprehensive clinical assessment performed to identify their current rehabilitation needs? 1.1.3 4 Based on the comprehensive clinical assessment (data item 3.1): 1.1.4 4.1 Were short-term rehabilitation goals agreed? 4.2 Were medium-term rehabilitation goals agreed? 4.3 Did the rehabilitation include an individualised, structured rehabilitation programme? 1.1.6 Information giving: 5 5.1 5.2 5.3 Did the patient receive the following information during their critical care stay: Information about their critical illness, interventions and treatments Information about the equipment used during their stay Information about any possible short-term and/or long-term physical and non-physical problems which may require rehabilitation A / B 1.1.7 14 of 19
Before discharge from critical care For those patients identified as at low risk: 6 6.1 Did they have a short clinical assessment to determine their risk of developing physical and nonphysical morbidity? 6.2 If Yes ; What risk(s) were identified? Physical: Unable to get out of bed independently Anticipated long duration of critical care stay Obvious significant physical or neurological injury Lack of cognitive functioning to continue exercise independently Unable to self ventilate on 35% O 2 or less Presence of premorbid respiratory or mobility problems Unable to mobilise independently over short distances Other(s): (state) 6.3 Non-physical: Recurrent nightmares Intrusive memories of traumatic events which occurred prior to admission New and recurrent anxiety or panic attacks Expressing a wish not to talk about their illness or changing the subject quickly Other(s): (state) 1.1.8 6.4 Date and time of this assessment: / / : hrs For those patients identified as at risk: 7a 7.1 Was a comprehensive reassessment performed to identify their current rehabilitation needs? 7b 7.2 Were the rehabilitation goals agreed or reviewed and updated based on the comprehensive reassessment? (data item 7.1) 1.1.9 1.1.11 8 8.1 8.2 8.3 Did the patient receive the following information before, or soon after their discharge from critical care: information about the rehabilitation care pathway information about the differences between critical care and ward-based care. Information about the transfer of clinical responsibility to a different medical team A 1.1.13 15 of 19
9 9.1 Was the patient given the contact details of the healthcare professional(s) coordinating their rehabilitation pathway on discharge from critical care? 1.1.1 Date and time of discharge from critical care: / / : hrs During ward-based care Date and time of admission: / / : hrs For those patients previously identified as at low risk before discharge from critical care: 10 10.1 Did they have a short clinical assessment to determine their risk of developing physical and nonphysical morbidity? 10.2 If Yes ; What risk(s) were identified? Physical: Unable to get out of bed independently Anticipated long duration of critical care stay Obvious significant physical or neurological injury Lack of cognitive functioning to continue exercise independently Unable to self ventilate on 35% O 2 or less Presence of premorbid respiratory or mobility problems Unable to mobilise independently over short distances Other(s): (state) 10.3 Non-physical: Recurrent nightmares Intrusive memories of traumatic events which occurred prior to admission New and recurrent anxiety or panic attacks Expressing a wish not to talk about their illness or changing the subject quickly Other(s): (state) 1.1.14 10.4 Date and time of this assessment: / / : hrs For those patients identified as at risk: 11 11.1 Was a comprehensive clinical reassessment performed to identify their current rehabilitation needs? 1.1.15 11.2 Date and time of this assessment: / / : hrs 16 of 19
12 12.1 Was an individualised, structured rehabilitation programme offered, based on the comprehensive clinical reassessment and the agreed or updated rehabilitation goals set before the patient was discharged from critical care? 1.1.16 Before discharge to home or community care For those patients identified as at risk: 13 13.1 For those patients who received an individualised structured rehabilitation programme during wardbased care, prior to discharge did they have: a functional assessment If Yes ; Did this assessment include: Physical dimensions: o physical problems o sensory problems o communication problems o social care o equipment needs Non-physical dimensions: o anxiety o depression o post-traumatic stress-related symptoms o behavioural and cognitive problems o psychosocial problems 1.1.20 14 14.1 Was the patient given the contact details of the healthcare professional(s) coordinating their rehabilitation pathway on discharge? 1.1.1 Information giving: 15 15.1 15.2 Before discharge was the patient given information on the following: their physical recovery diet and other continuing treatments managing their activities of daily living general guidance, especially for the family and/or carer, on what to expect and how to support the patient at home. Was the patient given a copy of the critical care discharge summary? 1.1.22 Date and time of discharge: / / : hrs 2 3 months after discharge from critical care 16 16.1 Date of review: For those patients with rehabilitation needs: Was a review undertaken? / / What was the profession of the person undertaking this review: 1.1.23 17 of 19
Appendix definitions Short clinical assessment Comprehensive clinical assessment Functional assessment Short-term rehabilitation goals Medium-term rehabilitation goals Physical morbidity Non-physical morbidity Multidisciplinary team A brief clinical assessment to identify patients who may be at risk of developing physical and non-physical morbidity A 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 An assessment to examine the patient s daily functional ability. It should include physical dimensions such as physical, sensory and/or communication problems and/or social care or equipment needs. It should also include non-physical dimensions, such as anxiety, depression, post-traumatic stressrelated symptoms and behavioural and cognitive problems. Goals for the patient to reach before they are discharged from hospital. Goals to help the patient return to their normal activities of daily living after they are discharged from hospital. Problems such as muscle loss, muscle weakness, musculoskeletal problems including contractures, respiratory problems, sensory problems, pain, and swallowing and communication problems. Psychological, emotional and psychiatric problems, and cognitive dysfunction. A team of healthcare professionals with the full spectrum of clinical skills needed to offer holistic are to patients with complex problems. The team may be a group of people who normally work together or who only work together intermittently. 18 of 19
Further information Click here for further information on reporting and monitoring the audit of NICE guidance in your organisation. Supporting implementation NICE has developed tools to help organisations implement the clinical guideline on critical illness rehabilitation (listed below). These are available on our website (www.nice.org.uk/cg83). Costing tools. Slides highlighting key messages for local discussion. Rehabilitation care pathway checklist. Audit support for monitoring local practice (this document). A practical guide to implementation, How to put NICE guidance into practice: a guide to implementation for organisations, is also available on our website (www.nice.org.uk/usingguidance/implementationtools). The guidance You can download the guidance documents from www.nice.org.uk/cg83. For printed copies of the quick reference guide or Understanding NICE guidance, phone NICE publications on 0845 003 7783 or email publications@nice.org.uk and quote N1825 (quick reference guide) and/or N1826 ( Understanding NICE guidance ). 19 of 19