WIREDGOV

NICE guidance published yesterday (25 March 2009) sets out to improve the quality of care patients receive during their recovery and rehabilitation after critical illness.

Approximately 110,000 people1 spend time in critical care units in England and Wales each year, the majority survive to be discharged home. For many patients recovery after critical illness is relatively straightforward but for others, discharge from critical care is the start of an uncertain journey to recovery characterised by problems such as, weakness, loss of energy and physical difficulties, anxiety, depression, post-traumatic stress (PTS) phenomena and, for some, a loss of mental faculty. Family members become informal caregivers, and this itself can exert an additional toll of ill-health and a strain on family relationships and financial security.

This guideline outlines the assessments and care patients should receive in hospital following a critical illness and the rehabilitation goals that will help patients recover to take part in usual daily activities as much and as rapidly as possible following discharge.

• Assessments should be carried out while the patient is in critical care and throughout their stay in hospital to identify any physical or psychological problems, likelihood of any problems developing in the future, and current and likely future rehabilitation needs.

• For patients at risk of poor quality or particularly slow recovery (due to what is known as physical and non-physical morbidity), a comprehensive clinical assessment need to be performed to identify current rehabilitation needs by healthcare professionals experienced in critical care and rehabilitation.

• Patients initially thought to be at low risk of poor recovery will still be assessed throughout their stay in hospital to make sure problems have not emerged.

• For patients at risk rehabilitation should start as soon as clinically possible to prevent avoidable physical and non-physical morbidity. This rehabilitation should continue as the patient recovers and is transferred to normal ward care.

• Before these patients leave hospital functional assessments need to be carried out to identify: any physical, sensory or communication difficulties; emotional or psychological problems; and any social care or equipment needs and how this could affect the patient’s daily life after they leave hospital.

• Patients should be given a copy of their critical care discharge summary and rehabilitation plan, which is also sent to their GP with details of their critical care stay and the contact details of the person who has been coordinating rehabilitation.

• Upon discharge from hospital patients should be given details about how to manage normal daily activity to get back to daily routines, information about returning to work and any benefits they might be entitled to.

• Patients with rehabilitation needs should be reviewed 2–3 months after their discharge from critical care.

Stephen Brett, Guideline Development Group Chair and Consultant in Intensive Care Medicine said: “Many people who have been treated in critical care units face substantial challenges while they are recovering from severe illness, trauma or major surgery. Although many people work extremely hard to help these individuals recover, up until now there has been no national attempt to define what key components should be part of their rehabilitation programmes and so the publication of this guideline represents a landmark for the NHS. The guideline has been developed using scientific studies where available, best practice from within the critical care community and related areas of rehabilitation, and, crucially, guided by the experiences of patients and families. The challenge for NHS Trusts and commissioners of services is to come together and ensure that these recommendations are adopted and that the rehabilitation needs of the patient are delivered from the earliest point possible in the critical care environment, throughout the hospital stay and continue once the patient is at home - which is often the point at which the real difficulties become clear”.

Bipin Bhakta, Consultant Physician and Clinical Director of Specialist Rehabilitation Services said: “People who have been treated within a critical care environment may have long lasting physical, psychological and emotional needs. The NICE guideline is an important information resource for NHS clinical staff, managers and commissioners on how to address these issues in an appropriate and timely manner. These guidelines will undoubtedly improve the quality of care received by these patients and their families”

Christina Jones, Nurse Consultant in Critical Care Follow Up, said: "Rehabilitation needs to start while the patient is still in ICU and should address both physical and psychological needs. The process of physical recovery can take months and the psychological problems, such a post traumatic stress disorder, which can occur, may have much longer term impacts on the patients' quality of life. Recognition and appropriate treatment of the problems patients face during their recovery means they have a chance to return to normal life".

David McWilliams, Senior Specialist Physiotherapist, said: “The NICE guideline for critical illness rehabilitation provides an excellent step forward in improving both the short and long term outcome of patients experiencing a period of critical illness. We know from experience that even a short period within critical care can have a huge effect on patients both physically and psychologically. What this guideline does is not only highlight these significant issues but also provides healthcare professionals with the guidance to maximise their interventions and make a very real difference to patients physical and psychological health, ultimately improving their quality of life”.

Peter Gibb, patient/carer member on the GDG said: “I believe this guideline marks a watershed in the treatment of patients recovering from critical illness. It recognises that recovery from critical illness does not end on discharge from hospital, let alone on discharge from intensive care. It provides a roadmap for the provision of rehabilitation services as part of a co-ordinated care pathway. It is my hope and belief that this will see an end to patients feeling like they’re the object in a game of ‘pass the parcel’ when it comes to receiving help in coping with recovery from critical illness.”

Notes to Editors

About the guideline

1. The rehabilitation after critical illness guideline is available at: www.nice.org.uk/CG0823

2. 'Critical care' is now used as the term that encompasses 'intensive care', 'intensive therapy' and 'high dependency' units.

3. Critical care is needed if a patient needs specialised monitoring, treatment and attention, for example, after routine complex surgery, a life-threatening illness or an injury.

4. If someone needs critical care, they can be said to have a ‘critical illness’.

5. 'Rehabilitation' is designed to help the process of physical and psychological recovery and help people cope with the physical, psychological and emotional effects associated with critical illness and with being a patient in critical care. Rehabilitation can help patients get physically and psychologically stronger after their experience through the use of gentle exercise programmes, advice and support.

Further quotes

6. Brian Cuthbertson, Professor of Critical Care said: “It is well known that critically ill patients who require intensive care suffer major and prolonged morbidity as well as an excess mortality in the years after intensive care. Currently NHS systems are not well developed to identify and rehabilitate these patients partly due to a lack of evidence to guide practice. This guideline offers a framework for health care professionals to prevent or minimise such morbidities and then rehabilitate these patients, starting within the intensive care phase and going on into the community after hospital discharge. It also encourages research into this field to allow future guidance on this topic to be genuinely evidence based”.

7. Barry Williams, Intensive Care Society Patient Liaison Committee member and patient/carer member on the GDG said: “These Guidelines offer the opportunity to make many patients’ lives better. The difficulties they and their relatives and carers face after critical care are daunting and without adequate and skilled rehabilitation can become devastating often leading to long term intractable problems. The health service has ignored these consequences for a number of years and it must in all conscience implement the guidelines without delay”.

About NICE

8. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

9. NICE produces guidance in three areas of health:
• public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS
• clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.