1. Re-Audit of the Rehabilitation Pathway for Critically Ill Patients against NICE Clinical Guideline 83 Kirsten Mitchell, Team Lead Respiratory Physiotherapist, ESHT, Sameena Ismail, Senior Physiotherapist, ESHT Introduction Approximately 110,000 people spend time in critical care units in England and Wales each year, with approximately 75% surviving to be discharged home (ICNARC, 2014). Research on the longer-term consequences of critical illness has shown that many of patients surviving critical illness experience significant and persistent problems with physical, non-physical (such as psychological, psychiatric or cognitive) and social functioning after discharge from critical care (Appleton et al, 2015). Rehabilitation strategies during critical care stay have been shown to (Chiang et al 2006; Thomas 2011) : - Slow functional deterioration - Decrease secondary complication - Decrease length of critical care stay - Decrease length of ventilator time StandardNICE CG83 Recommendation for Good Practice Achievement 1Named physiotherapist with relevant competencies to co-ordinate rehabilitation care pathway 100% 2Short clinical assessment (SCA) completed within 24hrs of admission to critical care 100% 3On a rehabilitation pathway100% 4aComprehensive clinical assessment (CCA) 2-5 days after critical care admission 100% 4bCCA reviewed weekly35% 5Individualised, structured rehabilitation programme with time-related rehabilitation goals 100% 6Rehabilitation goals updated weekly55% 7Referral to other multi-disciplinary teams75% 8Consider early discharge planning100% 9Conduct regular formal MDT meetings0% 10Provide information about a) critical care illness and interventions, b) equipment and c) physical / non-physical problems a) 61% b) 55% c) 55% 11Holistic reassessment prior to discharge to the ward 55% 12Provide information about a) the transition from critical care to ward-based care or b) different team a) 30% b) 35% 13Individualised, structured rehabilitation programme prior to discharge to the ward with short/medium term goals and onward referral for further rehabilitation 87% 14Provide information/contact details of further rehabilitation 60% 15Provide information about physical recovery, diet, managing daily activities or guidance for ongoing support. 56% 16Provide a critical care discharge summary0% 17Functional assessment prior to discharge from hospital 100% 18Review 2-3 months post-dischargeN/A Audit Objectives Compare ESHT critical care physiotherapy adherence to Sussex Critical Care Network Rehabilitation Pathway based on NICE CG83 (2009). Comparison with initial audit completed in March 2014. Use information to further guide service development at ESHT and county- wide. Evaluate current level of compliance with national rehabilitation CQUIN targets (D16 A/B/C 2015/16). Identified Risks and Concerns Current Practice Action PlanCompletion Date and Responsibility Goal setting (Standard 6, 7, 9,13) Goals not consistently time-specific or reviewed weekly Alter CCA electronic template to include prompts Cross-site staff education Weekly MDT meetings May 2015 KM, SI, CW Weekly CCA updates (Standard 4a, 4b,11, 13) Inconsistent updating of CCA Cross-site staff education Prompts in caseload books April 2015 KM, SI, AE, AW Information- giving (Standard 10 12, 14, 15) Variable provision or documentati on of information to patients Cross-site MDT education Alteration of template ICU steps leaflet availability Trial of patient diaries Information board ICU July 2015 KM, Critical Care Team Inadequate documentation for CQUIN targets (Standard 16) Daily verbal handover from nursing staff No evidence of rehabilitation prescription / discharge summary Formal documentation of SCA for all patients Prompt in caseload book Cross-site staff education Develop electronic rehabilitation prescription / discharge summary May 2015 KM, AE, AW, CW Conclusion SCA and CCA are now embedded in daily practice, completed consistently and timely. All appropriate patients are now placed on a holistic, structured and individualised rehabilitation pathway with documented rehabilitation prescription/ goals, early discharge plans, and follow-up post- discharge. Improve documentation regarding information-giving to patients Methodology Retrospective analysis from a purposive sample (n=20 patients) admitted to EDGH Critical Care Unit requiring physiotherapy (July 2014 – August 2014). Audit proforma based on NICE CG83 Audit Guidelines and WSFT, approved by Sussex Critical Care Network. Audit Standards The National Institute for Health and Clinical Excellence (NICE) published clinical guidelines for the rehabilitation of adults after a period of critical illness (CG83, NICE 2009) with specific recommendations for all appropriate patients: Key Findings and Recommendations References Appleton R et al. 2015. The incidence of intensive care unit-acquired weakness syndromes: a systematic review. J Intensive Care Society 16:126-136. Chaing et al. 2006. Effects of physical training on functional status in patients with prolonged mechanical ventilation. Physical Therapy 86:1271-81. Thomas A. 2011. Physiotherapy led early rehabilitation of the patient with critical illness. Physical Therapy Reviews 16:46-57. Acknowledgements: Karen Poole, Kirsti Bennett-Koster, Alexandra Wheeler, Ashwinder Ellens, ESHT Critical Care Units, Nick James, Clinical Effectiveness Facilitator; Produced by Medical Illustrations Department, EDGH