Rehabilitation after critical illness in adults
Gillian Sharpe, Lead Critical Care Physiotherapist, Chesterfield Royal Hospital, welcomes the update on NICE Quality Standard CG83 and the increased focus on rehabilitation of the critically ill it will bring.
Historically, mortality rates have been the main indicator of success following critical illness. Healthcare professionals working with the critically ill however, have long recognized that many of those who survive are left with significant physical and non-physical morbidity and often face a lengthy convalescence.
Publication of NICE CG83 in 2009 (Rehabilitation after critical illness) helped to shift the emphasis on outcome from the mere survival of patients to the optimisation of their recovery.
The publication of the NICE Quality Standards (Sep 2017) identifies 4 Quality Statements that further guide this process. Whilst some aspects of CG83 were open to interpretation, crucially the new standards clarify that they relate to patients in both Level 2 and Level 3 care and that they should be applied to patients having a length of stay of more than 4 days. That is not to say that we should not apply our professional judgement in identifying patients with a shorter length of stay who we feel are at risk of developing problems and do all that we can to reduce such risks.
Whilst some aspects of CG83 were open to interpretation, crucially the new standards clarify that they relate to patients in both Level 2 and Level 3 care and that they should be applied to patients having a length of stay of more than 4 days.
The new standards demand the early setting of rehabilitation goals, a formal handover of care when patients are transferred to general wards, the provision of patient information on discharge and the opportunity for ‘follow-up’ input.
One of the most rewarding aspects of my role as a physiotherapist in critical care is the sense of achievement gained, not only in seeing a patient survive critical illness, but in working with them to return them to a level of health and function which allows them to “get on with their life”.
It is clear that the patients who are most engaged in their therapy are those who have clear, personal goals to aim for and that the sooner these are set and rehabilitation starts, the better the physical recovery.
Time and again, I see that one of the most frightening times for a patient is the move from the perceived ‘safety’ of the critical care environment to the general wards. If the new standards encourage us to identify those at risk of such ‘relocation stress’ and to take steps to reduce this, they should be welcomed.
If the new standards encourage us to identify those at risk of such ‘relocation stress’ and to take steps to reduce this, they should be welcomed.
Having moved to the general wards, unfortunately the focus of patient care often shifts very quickly to discharge once ‘medically fit’. Whilst this is understandable on many levels, and is usually all that the patient desperately wants, awareness needs to be raised that many patients post critical illness are left with very significant rehabilitation needs. The reality of how desperately ill a patient has been, and the physical, emotional and psychological fallout from their stay on critical care, often only hits home with a patient once they leave hospital.
Patients need guidance on how to continue working towards their goals after discharge home, what further challenges they may face in their recovery and a point of contact when difficulties arise.
Hopefully, these new Quality Standards will raise awareness of these issues and allow appropriate and timely actions to be taken to optimise our patient’s recovery post critical illness.
The newly published NICE guidelines can be found here.