NICE Critical Illness and Rehabilitation guidelines

1. NICE Critical Illness and Rehabilitation guidelines Katy Osbaldeston Senior Physiotherapist in Intensive Care and Surgery Royal Sussex County Hospital

2. Why produce guidelines? “Guidelines can be used to develop standards to assess the practice of healthcare professionals, help in the education and training of healthcare professionals, help patients to make informed decisions, and improve communication between patients and healthcare professionals”

3. Principles of guidelines aim to improve the quality of clinical care assess the clinical and cost effectiveness of treatments or management approaches are advisory, but are expected to be taken into account by clinicians when planning care for individual patients are developed through a process that takes account of the views of those who might be affected by the guideline (usually including healthcare professionals, patients and their carers, service managers, NHS trusts, the wider public, government and the healthcare industries) are based on the best possible research evidence and expert consensus are developed using methods that are sound and transparent, and command the respect of the NHS and other stakeholders, including patients set out the clinical care that is suitable for most patients with the condition using the NHS in England and Wales. www.nice.org.uk/the guidelinedevelopmentprocess April 2007

4. The Background of Critical Illness Guidelines Published in March 2009 Covers “adults who, as a result of critical illness, have stayed in critical care and need rehabilitation”. Produced by Guidance Development Group (GDG) incl intensivists, Rehab consultants, PT, OT, N/S, psychologists and patients/carers.

5. Why did we need them? Poor recognition or management of physical/psychological and social function post ITU d/c Acknowledgement of psychological disturbance post ITU (PTSD, anxiety, memory loss), not often identified/treated Lack of national standards of rehabilitation – no ‘gold standard’ “No evidence based guideline that addresses the identification, timing and nature of effective interventions”

6. Role of the GDG Identify ineffective interventions and aim to recommend change in approach to care Evaluation of screening tools and optimization of timing of their use Demonstrate clinical and cost effectiveness of rehab and optimize timing Advise specific information for patients and their carers

7. What was recommended? Short clinical assessment: a brief clinical assessment to identify patients who may be at risk of developing physical and non-physical morbidity. Comprehensive clinical assessment: a 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 assessment: an assessment to examine the patient’s daily functional ability. Short-term rehabilitation goals: goals for the patient to reach before they are discharged from hospital.

8. What was recommended? Medium-term rehabilitation goals: goals to help the patient return to their normal activities of daily living after they are discharged from hospital. 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. Multidisciplinary team: a team of healthcare professionals with the full spectrum of clinical skills needed to offer holistic care to patients with complex problems. The team may be a group of people who normally work together or who only work together intermittently.

9. Between the lines The rehab encompasses physical and non physical – perhaps something not usually thought of by Critical Care The use of an MDT may be new to many intensivists Encourages physical rehab as early as possible, so challenges the sedation regimes Encourages critical care to ensure good discharge planning is continued to the ward and then home

10. Cont. Has gained insight into the difficulties encountered by ward staff with regards to ‘difficult’ discharges and challenges the critical care team to start discharge planning asap Encourages communication amongst the MDT in all areas of rehab Suggests to some medics about ‘thinking outside the box’ i.e. the box of the ITU

11. What does it mean for us? We need to develop and review our treatment plans and goals regularly Need to ensure we’re up to date with evidence based treatment Use of more ‘solid’ outcome measures and good documentation.

12. What does it mean for us? Need to ensure our ITU discharges are communicated fully to the accepting Physio Co-development of rehab MDT ward round – will be consultant of the week, PT and lead nurse. Communication files for complex patients MDT discharge proforma