The Patients Journey- Critical Care And Beyond Presented by Donna Egan- Outreach coordinator With thanks to: Scott Hendry- ICU follow up nurse Sally o Loghlen – Outreach Physiotherapist

Aim of the session To understand the patient journey and challenges faced by ward teams, patients and carers post critical illness

NICE recommendations: The recommendations cover the following areas: Key principle of care During the critical care stay 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

NICE Guidelines influencing the post ICU population No 50 (2007)- Acutely Ill Patients in hospital. No 83 (2009) – Rehabilitation after Critical Illness. No 103 (2010) – Delirium: Diagnosis, Prevention and Management. No 22 (2007) – Anxiety. No 90 (2009) – Depression. No 32 (2006) – Nutrition Support.

“There is often little or no support for these people once discharged from hospital.” “Almost three-quarters of them (73%) reported having moderate or severe pain a year after discharge, while 44% were significantly anxious or depressed. Negative impact on employment and family income Commonly have a care requirement after discharge from hospital (Griffiths et al May 2013) Recent studies

The Patients Journey From Critical Illness to Health Listening and Using data to plan care

Our population LOS in ICU median approximately 3 days Apache II median unchanged( 16) Our role: Increasing population by 22% post ICU They said…… Prevention of deterioration SupportAdviceReferralCommunication

Patient Satisfaction Memories of discharge to the ward “8.30pm Nightmare – staff changing, no one introducing themselves initially, told earlier in the day that was not moving to a ward”. “Too ill to remember”. “I was greeted by smiling faces from the nurses”. “not sure what to expect, the head nurse was very kind and said I will be taken care of”.

Patient satisfaction How organised was the transfer? Did you feel rushed? Communication

Anxieties on transfer “didn’t remember much of transfer” “How I would cope without the extra help from the nurses”. “very satisfied with care” “Unsure of what was going to happen”. “..nurses on the ward hadn’t a clue about what I had done, they didn’t have my records”.

Inpatient Anxiety and Depression

Feedback from 7% (42 patients) invited to clinic 45% have clear memories >80% felt nothing else could be done to improve the ICU experience 37% had bad dreams 83% had hallucinations with 29% having flashbacks Memory of ICU at 3 months post discharge

Mobility in the First 48 hours

Clinic at 3 months (42 patients) 4.7% of total population said health had not returned to what it was before admission to the ICU 3.3 % said health was worse than pre ICU admission 2.3% (n=14) still had problems with washing and dressing 4.4% could not do things that they could previous due to their health

Problems with walking 23/594(3.8%)

Enough Rehab?

Nutrition

We listened ….we did…. Care pathways Psychological Physical During the critical care stay Night time discharge KPI New unit TV and telephone at each bed

Discharge Planning/ Communication Prepare patient for ward Advise them of change in level of care and monitoring Pre Discharge Review: Sleep Anxiety/depression Nutrition – MUST and Weight! Tracheostomy Care Plan & Equipment Medical Discharge Summary- sticker Before discharge from critical care

Post Critical Care During ward-based care

Resource management

Improvements in walking test 6 min walk: 341 to 439m Reduction in Depression Positive Feedback 2–3 months after discharge from critical care Before discharge to home or community care

In their own words…. video

The Way Forward Patient Forum Review of pathways

Finally, Remember the person… The Patients Journey From Critical Illness to Health

References 1. An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12- month follow-up study John Griffiths 1,2, Robert A Hatch 1, Judith Bishop 1, Kayleigh Morgan 1, Crispin Jenkinson 3, Brian H Cuthbertson 4 and Stephen J Brett 5* Critical Care 2013, 17:R100 Published: 28 May 'More support needed' for patients after intensive care By Jane Dreaper