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

demonstrated that an individualised 8-week home-based should enable the development of a series of seamless
physical rehabilitation program did not increase the services that start recovery and rehabilitation activities for
underlying rate of recovery in a sample of 183 patients, a patient while in ICU, is carried through to hospital
with no group differences identified for 6MWT distances discharge and continues into the community setting.
or HRQOL at 8 weeks or 6 months. 158 The authors recom-
mended further research to improve the effects of the
intervention by increasing exercise intensity and fre- SUMMARY
quency, and identifying individuals who would benefit It is now acknowledged that continuity of care for indi-
from a home-based rehabilitation intervention. Other viduals with a critical illness extends beyond the immedi-
research is continuing in this area, but findings are not ate event to include non-ICU hospital care and community
yet available. e.g.131 Findings from other clinical cohorts services. Physical and psychological sequelae for some
may also inform the development of rehabilitation inter- individuals following a critical illness are well docu-
ventions, for example with the use of web-based or mented. Beginning physical rehabilitation and a range of
mobile technologies. 159
psychological strategies have been used to limit these
Further research is therefore also required in this post- effects in some studies, although more comprehensive
hospital period 160 as well as across the continuum of and system-wide interventions require implementation
critical illness. e.g.131 With further study, future continuity and evaluation to improve the evidence base for this
of care and follow-up services after hospital discharge important area of critical care practice.

Case study

Mr Gilardi was a 55-year-old man admitted to ICU with community- admission to ICU would occur. The doctor contacted the liaison
acquired pneumonia. He required five days of mechanical ventila- nurse service for advice as to how to support Mr Gilardi.
tion and was then discharged to the high dependency unit for
three days and then to a medical ward. An ICU liaison nurse saw A liaison nurse phoned Mr Gilardi to invite himself and his family
him three times prior to discharge from the ward where he initially to attend for a review of his time in ICU with the now established
had some confusion and was suffering from hallucinations. He did ICU follow-up service. At his appointment he reported recurrent
have some insight into this and reported that this was no longer nightmares, difficulty in sleeping, was not keen to go outside, and
bothering him. An ICU follow-up service was not in operation at was finding it difficult to discuss any events surrounding his ICU
the time of his discharge home. admission. These symptoms had now been present for almost a
year, and the follow-up nurse was concerned that Mr Gilardi may
Mr Gilardi then attended an outpatient review for a recurring have developed a posttraumatic stress disorder. The nature of his
gastrointestinal problem a few months later. At this appointment enduring symptoms was discussed, and it was decided that the
his doctor was concerned that he still appeared to be traumatised best course of action was for him to be referred to the local liaison
psychologically by his ICU experience. This was highlighted when mental health services. Mr Gilardi is now receiving psychiatric care
Mr Gilardi stated that he did not want any further treatment for with the aim of improving his quality of life and allowing him to
his gastrointestinal problem if there was any possibility that an undergo additional treatment for his gastrointestinal issue.

Research vignette
Jones C, Bäckman C, Capuzzo M, Egerod I, Flaatten H et al. Intensive development of acute PTSD. The intervention patients received
care diaries reduce new onset post traumatic stress disorder fol- their ICU diary at 1 month following critical care discharge and the
lowing critical illness: a randomised, controlled trial. Critical Care final assessment of the development of acute PTSD was made at 3
2010; 14(5): R168–R178. months.
Abstract Results
Introduction 352 patients were randomised to the study at 1 month. The inci-
Patients recovering from critical illness have been shown to be at dence of new cases of PTSD was reduced in the intervention group
risk of developing Post Traumatic Stress disorder (PTSD). This study compared to the control patients (5% versus 13%, P = 0.02).
was to evaluate whether a prospectively collected diary of a Conclusions
patient’s intensive care unit (ICU) stay when used during convales- The provision of an ICU diary is effective in aiding psychological
cence following critical illness will reduce the development of new recovery and reducing the incidence of new PTSD.
onset PTSD. Critique
Methods Despite a relative lack of empirical data, the use of patient diaries
Intensive care patients with an ICU stay of more than 72 hours were for ICU patients has become popular innovation over the last
recruited to a randomised controlled trial examining the effect few years. As noted earlier in this chapter, patients’ memories of
of a diary outlining the details of the patients ICU stay on the intensive care have been consistently related to subsequent