Critical Illness Rehabilitation

Critical care encompasses any type of intensive treatment (level two and three care) which can include a stay on either the intensive care unit or the high dependency unit. It is estimated that each year 110,000 people will be admitted to a critical care unit (in England and Wales).^[1]The long-term adverse consequences on both physical and mental well-being of critical care are only recently coming to light. This includes short-term problems, such as loss of energy and more longer-term issues, including cognitive dysfunction.^{[1, 2, 3]}

Risk factors for developing adverse consequences

• Longer duration of stay (but even short stays can be associated with problems)
• Presence of pre-morbid conditions

Adverse consequences relating to critical care^[1]

Physical

• Weakness
• Loss of energy
• Pain
• Critical illness polyneuropathy and/or myopathy
• Development of contractures
• Respiratory difficulty
• Swallowing difficulty
• Communication problems

Non-physical

• Anxiety
• Depression
• Post-traumatic stress disorder
• Cognitive dysfunction
• Emotional lability
• Family/friends have to become carers
• Socio-economic problems, eg financial strain, inter-relationship difficulties

Key factors in a critical illness rehabilitation^[1]

Attention to these factors from day one will ensure that the patient has an optimum chance to recover. They include:

• Respecting patient autonomy
  • Taking into consideration the patient's need and preferences
  • Promoting informed decision-making
• Good communication
• Involvement of family/carers from the beginning (if the patient agrees)
• Regular review and update of goals

Rehabilitation goals

Rehabilitation goals should be set from the beginning of the patient's admission to hospital and there should be ongoing review and development of plans during their stay. Goals are of two types:

• Short-term rehabilitation goals
  • These goals are to be achieved before discharge from hospital.
• Medium-term rehabilitation goals
  • These are goals aimed to get the patient back to their normal level of functioning so they can manage their activities of daily living as prior to admission. These will be set during the patient's hospital stay but will probably not be reached until post-discharge.

What happens during critical care stay^[1]

• Patients should be briefly assessed early on to determine their risk of developing physical and/or non-physical problems.
  • Indicators of developing non-physical problems include the presence of recurrent nightmares or anxiety.
  • Indicators of developing physical problems includes factors such as, unable to mobilise independently or inability to self-ventilate on 35% or less oxygen.
• This initial assessment will usually involve nurses and doctors. They will also review medications and nutritional needs.
• Following this, a more comprehensive assessment of specific areas may be required, eg full neurological examination, formal swallowing assessment.
• Depending on the findings, referrals to appropriate specialists may be made - leading to a multidisciplinary team approach.
• On the basis of these initial reviews, a plan consisting of both short- and medium-term goals can be initiated.

Pre-discharge to general ward from critical care^[1]

• If the patient was deemed as low-risk on the initial assessment then a repeated short assessment will usually take place prior to discharge from critical care.
• High-risk patients will already be on their rehabilitation programme and should be comprehensively re-assessed to determine whether any changes in goals are needed at this stage.
• One of the most important factors when a patient is discharged from critical care to a general ward is good handover to the accepting medical team. Most critical care units will provide a typed discharge letter detailing the patient's stay and listing their current medications and any outstanding action plans. Doctors should formally inform the team seniors about the patient. Nursing staff will usually perform a formal handover and it is always good to mention problems, such as sleeping difficulty, hallucinations, etc.

Management on the general ward

• Further assessments will take place as above and the main objective will be to reach the short-term goals.
• Patients discharged from intensive care units will usually be visited by a member of that team a few days post-discharge to see how they are managing. This is also a good time for the patient (and relatives) to ask any questions specifically relating to their stay on intensive care.
• Any evidence of psychiatric disorders, including post-traumatic stress disorder, merit in-patient review by psychiatrists.
• Patients will normally be screened by the nursing staff and, if appropriate, referred to social worker, physiotherapists and occupational therapy teams.
• The outcome of the multidisciplinary approach will result in the production of medium-term goals in the form of a structured rehabilitation programme lasting a minimum of 6 weeks. This will usually begin as an in-patient and be completed post-discharge.
• Patients should only be discharged once everything that is needed is in place so that they are going to a safe environment with adequate support. Family and carers may also need adequate support systems.

Pre-discharge from hospital^[1]

• Further assessment of both physical and non-physical problems should occur.
• Patients should have contact details of the team they were under and details of any further out-patient appointments.
• Again, handover to the patients primary care physician and community teams is crucial. Discharge letters do not always have enough space to adequately relay all the necessary information and so it may be better to type a separate letter. If the patient's stay was particularly complicated or there are outstanding issues then it is good practice to speak to their primary care physician. Include results of pertinent investigations and at a minimum the blood results pre-discharge. Use the following as a checklist:

  What to include in a discharge summary:

  • Date of admission/discharge to various departments/units
  • List of major diagnoses
  • List of medications - include dose, timing and anticipated duration
  • Detailed section on patients stay - it is easy to list the dates and what happened, eg '3rd Jan treated for MRSA sepsis'
  • Any outstanding issues eg investigations - what are they and who will follow them through?
  • Conclusions from the various multidisciplinary teams involved, eg occupational therapist, social worker
  • Follow-up for the patient
  • Information given to patient and/or family/carers
  • Contact details of ward and medical team involved - this should be written clearly and it is helpful to give the direct ward telephone number and doctor's bleep
• Give a copy of the letter and any paperwork to the patient so they have it at hand in case they fall ill in the few days post-discharge. Faxing a copy on the day of discharge to the primary care practice is also helpful.
• Medications should all be reviewed prior to discharge.

Ongoing rehabilitation in the community^[1]

• The patient's rehabilitation needs and goals should be reviewed 2-3 months post-discharge from hospital. This can occur in the community or in clinic.
• Review presence or absence of the physical and non-physical problems listed above.
• Remember that financial problems may not become apparent until a few months after discharge, and refer early to social workers.
• Ongoing problems, eg depression or myopathy may require referral to specialists.
• Patients will often ask about when they can return to work. This will in part depend upon the underlying condition, how strenuous their job is and most importantly on how they feel. It might be a good idea for patients to return back for a half day to begin with and gradually increase this as they tolerate.
• In terms of driving, similar rules apply as returning to work but it is good practice to consult the DVLA guidance.^[4]