Page 94 - ACCCN's Critical Care Nursing

Recovery and Rehabilitation 71

TABLE 4.8 Example of considerations in setting up a nurse-led follow-up service

Consideration Action
Staff preparation ● Follow-up Nurse attended an established clinic
● Attended study days in relation to psychiatric problems
● Discussion and frequent contact with Consultant Psychiatrist in Psychotherapy
● Plans to access formal education preparation in Cognitive Behaviour Therapy
● Plans to ‘shadow’ a community psychiatric nurse
Accommodation ● Outpatient accommodation with an area close to but separate from the ICU
In-hospital follow-up ● All level patients are seen prior to hospital discharge where the follow-up clinic is explained and an
appointment given; relatives are included in this appointment
● The options for telephone consultation and/or home visits are discussed and negotiated
Timing of clinic and number of ● Initial appointment 2–3 months after ICU discharge
appointments ● Further appointments determined by patient need or request
● All patients can contact the follow-up nurse without formal appointments
Structure of clinic ● Patients’ case notes reviewed prior to the clinic appointment and discussed between nurse and
intensivist
● General assessment questionnaire forms the basis of the discussion between the nurse and patient
● Standardised measures include: Short-Form 36, Hospital Anxiety and Depression Scale, and Intensive
Care Experience Questionnaire
● Patients are offered a visit to the ICU if they do not ‘trigger’ referral on the Hospital Anxiety and
Depression Scale
Documentation ● General assessment questionnaire forms the basis of the record of appointment; the nurse records any
additional information on this form
Referral criteria ● There are clear referral criteria for a number of specialties, developed in collaboration with intensivists,
other medical specialties and allied health professionals
Letter to General Practitioner ● A letter summarising the appointment and any recommendations is sent to the patient’s GP

demonstrated differences between groups for the primary Other considerations
(HRQOL: SF-36) or secondary outcome measures It is important to consider that while interventions may
(anxiety and depression: Hospital Anxiety and Depres- not always benefit patients, it also has to be demonstrated
sion Scale; post-traumatic stress: Davidson Trauma that they cause no harm and therefore initiating a new
Scale). There were also no differences between patients service has governance issues. There are also knowledge
who had a short intensive care stay and those with and skill-set development issues. Intensive care nurses
longer stays. 146
tend not to have training in managing patients on an
There is little doubt that patients value intensive care outpatient basis and new skills have to be learned. They
follow-up, but there is no evidence to support any may also not have knowledge and experience in manag-
improved patient outcomes. 157 There may be a number ing many of the patient problems evident at follow-up,
146
of reasons for this finding. The study intervention was in particular the psychological issues. Other consider-
based on existing models of ICU follow-up and our con- ations include accommodation, documentation, com-
temporary understanding of patient recovery has evolved munication with other healthcare professionals and
since then. For example, no recognition was made of evaluation processes. Table 4.8 provides an example of
cognitive function and the effects of delirium, and perhaps how these issues were addressed when setting up a
the timing of the intervention was too late. It may also follow-up service in a Scottish teaching hospital; an
be that particular subgroups benefited, e.g. those who evolving service that developed from the PRaCTICaL
received psychiatric or psychological referral, but the study. 146 A more flexible approach is used with different
study was not sufficiently powered to detect this. options discussed with the patient regarding delivery,
with a telephone consultation, home visit and/or clinic
Other models that allow more flexibility should therefore appointment.
be considered. Telephone contact in the initial weeks
after discharge can offer some reassurance to patients and
also identify early problems. Patients could then be either HOME-BASED CARE
referred to other specialties, their outpatient appoint- While there are home-based programs to manage ongoing
ments coordinated or invited to return to a follow-up care for some clinical cohorts (e.g. patients with heart
clinic if they experience identified difficulties. Home visits failure) no specific follow-up programs currently exist to
could also be an option for those who are physically or support survivors of a critical illness. Initial studies in this
practically unable to return to a clinic or for those with setting are also yet to identify an optimal intervention to
avoidant behaviours. improve recovery. A recent Australian multi-site study