Rehabilitation after critical illness Implementing NICE guidance 2009
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 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: Key principle of care Before discharge from critical care During ward-based care Before discharge to home or community care 2– 3 months after discharge from critical care Information During the critical care stay
Key principle of care 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
During the critical care stay • 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
Before discharge from critical care • 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
During ward-based 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
Before discharge to home or community 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
2– 3 months after discharge from critical 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
Information and support Stage of care Information to cover Critical care Illness, treatment and equipment used, possible rehabilitation needs At discharge Rehabilitation pathway, differences to expect in from critical 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 Otherapists, e. g. , dietetics, speech and language Estimated cost of implementation 3, 629 56, 506
Potential benefits per 100, 000 population Description Reduced length of stay on general wards as a result of early intervention Resources released (£ per year) 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/CG 83 for: • • the guideline the quick reference guide ‘Understanding NICE guidance’ costing report and template audit support discharge checklist joint position statement
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