Rehabilitation after critical illness
Implementing NICE guidance
2009
NICE clinical guideline 83
What this presentation covers
Background
Scope
Definitions
Recommendations
Discussion
Find out more
Background
• Approximately 110,000 people are admitted into critical
care units in England and Wales each year
• Most patients surviving critical illness have significant
physical and non-physical morbidity and undergo a lengthy
convalescence
• This morbidity is frequently unrecognised and, if identified,
may not be appropriately assessed or managed
Scope
The recommendations are
for adults with physical and
non-physical rehabilitation
needs as a result of a period
of critical illness
Definitions
Physical
morbidity
Problems such as muscle loss, muscle weakness, musculoskeletal
problems including contractures, respiratory problems, sensory
problems, pain, and swallowing and communication problems
Non physical
morbidity
Psychological, emotional and psychiatric problems, and cognitive
dysfunction
Clinical
assessments
Short : brief assessment to identify patients who may be at risk of
developing physical and non-physical morbidity
Comprehensive: more detailed assessment to determine the
rehabilitation needs of patients who have been identified as being at
risk of developing physical and non-physical morbidity
Functional: to examine the patient’s daily functional ability
Recommendations
The recommendations cover the following areas:
Key principle of care
Before discharge from critical care
During ward-based care
Before discharge to home or
community care
2–3 months after discharge from
critical care
Information
During the critical care stay
Key principle of care
Healthcare professional(s) with the appropriate
competencies should coordinate the patient’s
rehabilitation care pathway. As well as providing
information and support, they should:
• ensure that rehabilitation goals are regularly
reviewed and updated
• ensure delivery of structured and supported
rehabilitation when applicable
• liaise with other relevant settings
2–3 months after discharge
During the critical care stay
• Perform a short clinical assessment to determine the
patient’s risk of developing physical and non-physical
morbidity
• Perform a comprehensive assessment to identify
current rehabilitation needs and to agree short-term and
medium-term rehabilitation goals for patients at risk
• Start rehabilitation as early as clinically possible for
patients at risk
Before discharge from
critical care
• Perform a short clinical assessment for patients
previously identified as being at low risk
• Perform a comprehensive clinical reassessment for
patients at risk to identify rehabilitation needs and to
agree or review and update rehabilitation goals
During ward-based care
• Perform a short clinical assessment for patients
previously identified as being at low risk before
discharge from critical care
• Perform a comprehensive clinical reassessment for
patients at risk
• Provide an individualised, structured rehabilitation
programme for patients at risk
Before discharge to home or
community care
• Perform a functional assessment of physical and
non-physical dimensions
• Ensure that arrangements are in place, if continuing
rehabilitation needs are identified before the patient
is discharged, including appropriate referrals for
ongoing care
2–3 months after discharge
from critical care
• Review the patient and perform a functional assessment
of their health and social care needs
• Refer the patient to the appropriate rehabilitation or
specialist services if:
- the patient is recovering at a slower rate than
anticipated
- the patient has developed unanticipated morbidity that
was not previously identified
Information and support
Stage of care
Information to cover
Critical care
Illness, treatment and equipment used, possible
rehabilitation needs
At discharge
from critical
care
Rehabilitation pathway, differences to expect in
care such as environment, staffing and monitoring.
Transfer of responsibility and handover of care,
possible rehab needs and if applicable other
problems such as sleeping, nightmares and
adjusting to ward
At discharge to
home/
community care
Expected recovery, diet and other continuing
treatments, managing daily living including driving,
returning to work, benefits where applicable,
statutory and non-statutory support services, and
general guidance for the family and/or carer
Potential costs
per 100,000 population
Description
Costs
(£ per year)
Physiotherapists – critical care early intervention
19,460
Clinical Psychologists – hospital and follow -up services
14,759
Physiotherapists – community follow -up services
18,658
Other therapists, e.g., dietetics, speech and language
Estimated cost of implementation
3,629
56,506
Potential benefits
per 100,000 population
Description
Reduced length of stay on general wards as a result of early
intervention
Resources
released
(£ per year)
3,321
Reduced length of critical care stay as a result of early
intervention
26,532
Estimated total benefits from implementation
29,853
Discussion
• At what stage do we assess rehabilitation needs?
• How do we currently coordinate the rehabilitation of
patients during and after critical illness?
• How can we ensure adequate provision of a
multidisciplinary team to deliver rehabilitation
services?
• What is the current provision of community-based
rehabilitation services and do we need to improve
this?
Find out more
Visit www.nice.org.uk/CG83 for:
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the guideline
the quick reference guide
‘Understanding NICE guidance’
costing report and template
audit support
discharge checklist
joint position statement