Page 91 - ACCCN's Critical Care Nursing

68 S C O P E O F C R I T I C A L C A R E

WARD-BASED POST-ICU RECOVERY optimal duration, intensity and frequency of interven-
tions is not yet clear. 131
Follow-up services for survivors of a critical illness in
Australia and New Zealand have occurred sporadically in RECOVERY AFTER HOSPITAL
individual units with interested clinician teams, 133 but
there is currently no widespread systematic approach to DISCHARGE
recovery and rehabilitation and the management of phy- Of patients who survive their critical illness to hospital
sical, psychological or cognitive dysfunctions beyond discharge, 5% will die within 12 months, and their risk of
clinical stability and deterioration with ICU Liaison ser- death is 2.9 times higher than for the general population.
2
vices 134,135 or Medical Emergency Teams (MET). 136 Functional recovery can be delayed in some individuals
30
Commencement or continuation of rehabilitation activi- for 6–12 months 3-5,145 or longer. In a recent study in
ties in the general wards after discharge from ICU high- Norway, only half of 194 patients had returned to work or
lights a potentially different set of challenges, particularly study one year after surviving their critical illness. 145
in terms of physiotherapy resources, involvement of other There is however only limited research and mixed study
medical teams, compliance to a prescribed plan. While findings identifying specific interventions during the
some cohorts of critically ill patients (e.g. pulmonary, post-hospital period that may improve a patient’s recov-
cardiac, stroke, brain injury) have defined rehabilitation ery trajectory and health outcomes. Most work has
pathways, 128 patients with other clinical presentations involved practice evaluations or studies of outpatient
may not be routinely prescribed a rehabilitation plan or ‘ICU follow-up’ clinics, e.g.91,146,147 while there is some
be referred to a rehabilitation specialist. beginning work exploring home-based programs. e.g.148,158
For Australian and New Zealand patients who survive to
ICU discharge, approximately 3% will die prior to hospi- ICU FOLLOW-UP CLINICS
tal discharge. 137 Some work in Europe on prognosis post-
ICU discharge using the 4-point Sabadell Score (0 = good Systematic follow-up for survivors of a critical illness after
prognosis; 1 = long-term poor prognosis; 2 = short-term hospital discharge emerged in the UK in the early 1990s,
poor prognosis; 3 = expected hospital death) 138 demon- after a number of government reviews on the cost and
strated that subjective intensivist assessment was able to effectiveness of critical care services highlighted: the need
139
predict the risk of patient mortality, and conversely to evaluate longer-term patient outcomes, in particular
those patients potentially suitable for rehabilitation. quality of life; 149 and recognised that patients had sequelae
that were best understood and managed by ICU clini-
Impairment in functional ability can be significant for cians. In 2000, the UK Department of Health published
some patients after ICU-discharge. In a small Dutch a comprehensive review of critical care services. With
observational study (n = 69) of patients who had mechan- emerging albeit limited evidence of the benefits of an ICU
ical ventilation of 48 hours of more, over 75% of the follow-up clinic, the review recommended the provision
sample were totally or severely dependent for activities of of follow-up services for those patients expected to
daily living (Barthel Index 0–12) 4 days after ICU- benefit. Importantly, this review also recommended
150
discharge. 140 Close monitoring and early rehabilitation collection of patient recovery and outcome data; this has
during this period was therefore recommended. been facilitated through follow-up clinics. The review did
Specific ward-based rehabilitation interventions follow- not however indicate how these services should be deliv-
ing ICU discharge are beginning to be investigated. Some ered or funded. The emerging pattern in the UK has
exploratory work in the UK implemented a generic reha- therefore been to invite patients to a follow-up clinic.
bilitation assistant to support enhanced physiotherapy The first intensive care follow-up clinics were established
and nutritional rehabilitation in collaboration with ward- in the UK in the early 1990s, driven by a few interested
151
based staff. 141,142 Feasibility of the role and process was and committed intensive care clinicians. From this early
established, and further work in a larger sample will test beginning the number of clinics has increased; a recent
the efficacy of the intervention. 142
survey noted at least 80 follow-up clinics from approxi-
151
The benefits of physical exercise training for patients with mately 300 ICUs throughout the UK. A number of
COPD was affirmed in a recent review, with recommen- decisions are required when implementing a follow-up
dations focused on maintenance of health behaviour clinic, as different models have evolved as nurse-led,
change, 143 and these guidelines could be applied to some doctor-led or a combination of both; more than half in
cohorts of critically ill survivors. Identification of the the UK are currently nurse-led. Some services include
151
most effective level of intervention however remains input from allied health professionals and psychologists,
elusive. One Australian study of acute medical patients although this multi-disciplinary approach is less common.
(not after critical illness) noted that individually tailored This may be a reflection of resource implications but is
physical exercise (20–30 minutes twice daily, 5 days per in keeping with the general development of nurse-led
week) in hospital was not sufficient to influence func- services within the UK. Many clinics restrict patients
tional activity at discharge. 144 Further research is therefore invited to return to those with an ICU length of stay of
required to test specific interventions during the post-ICU at least 3 or 4 days. This decision is often based upon
hospital period aimed at improving the recovery trajec- resources rather than evidence, as patients who have a
tory and health outcomes for patients with limited physi- shorter stay may also have subsequent physical and psy-
cal function. As noted with in-ICU rehabilitation, the chological problems. 146