Rehabilitation after critical illness: summary of NICE guidance
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b822 (Published 25 March 2009) Cite this as: BMJ 2009;338:b822
- Toni Tan, technical analyst1,
- Stephen J Brett, consultant in intensive care medicine2,
- Tim Stokes, associate director1
- on behalf of the Guideline Development Group
- 1Centre for Clinical Practice, National Institute for Health and Clinical Excellence, Manchester M1 4BD
- 2Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS
- Correspondence to: S Brett stephen.brett{at}imperial.ac.uk
Why read this summary?
More than 110 000 people are admitted to critical care units in England and Wales each year,1 of whom 75% survive to be discharged home. Many of these people experience considerable and persistent problems with physical, non-physical, and social functioning after discharge from critical care. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on rehabilitation after critical illness for adult general critical care patients.2
Recommendations
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice and, in this guidance, also from lessons that can be derived from other clinically relevant fields of patient care. Evidence levels for the recommendations are given in italic in square brackets.
Key principles of care
To ensure continuity of care, healthcare professionals with the appropriate competencies should coordinate the patient’s rehabilitation care pathway. The healthcare professionals may be from intensive care or other services (including specialist rehabilitation medicine services) that have access to referral pathways and medical support (if not medically qualified). Key objectives of the coordination are:
To ensure that rehabilitation goals are reviewed, agreed, and updated throughout the patient’s rehabilitation care pathway
To ensure delivery and support of the structured and supported self directed rehabilitation manual (a specific type of rehabilitation programme),3 when applicable
To ensure that information, including documentation, is communicated to other relevant hospitals and to other rehabilitation services and primary care services
To ensure that patients have the contact details of the coordinating healthcare professional(s) on discharge from critical care and again on discharge from hospital.
[All the above recommendations are based on the experience and opinion of the Guideline Development Group (GDG)]
During the critical care stay
Perform a short clinical assessment to determine the patient’s risk of developing specific prolonged physical and non-physical morbidity associated with their underlying illness and their stay in the critical care unit (box 1).
Box 1 Definitions of physical and non-physical morbidity and examples from the short clinical assessment that may indicate the patient is at risk of developing physical and non-physical morbidity*
Physical and non-physical morbidity
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
Examples that may indicate the patient is at risk
Physical morbidity—Unable to get out of bed independently; anticipated long duration of critical care stay; obvious considerable physical or neurological injury; lack of cognitive functioning to continue exercise independently; unable to self ventilate on 35% of oxygen or less; presence of premorbid respiratory or mobility problems; unable to move about independently over short distances
Non-physical morbidity—Recurrent nightmares, particularly when patients report trying to stay awake to avoid nightmares; intrusive memories of traumatic events that have occurred before admission (for example, road traffic accidents) or during their critical care stay (for example, delusional experiences or flashbacks); new and recurrent anxiety or panic attacks; expressing the wish not to talk about their illness or changing the subject quickly
*This list is not exhaustive, and healthcare professionals should use their clinical judgment
For patients at risk:
Perform a comprehensive clinical assessment to identify their current rehabilitation needs
Agree short and medium term rehabilitation goals, documenting these in the patient’s records
Start an individualised, structured rehabilitation programme as early as possible; this should include introducing measures to prevent avoidable physical and non-physical morbidity and reviewing nutritional support,4 with frequent follow-up.
[The above three recommendations are based on the GDG’s experience and opinion]
Before discharge from critical care
For patients previously identified as being at low risk, perform a short clinical assessment to determine their risk of developing prolonged physical and non-physical morbidity (box 1).
For patients newly identified as being at risk and for patients who have already started individualised, structured rehabilitation in critical care:
Perform a comprehensive clinical reassessment to identify current rehabilitation needs, paying particular attention to physical, sensory, and communication problems and to pre-existing or current psychological or psychiatric distress (box 2)
On the basis of this reassessment, agree or review and update the rehabilitation goals.
Ensure that the transfer of patients and the formal structured handover of their care are in line with the NICE recommendations for caring for acutely ill patients in hospital.5
[All the above recommendations are based on the GDG’s experience and opinion]
Box 2 Symptoms from the functional assessment that may indicate the presence of physical and non-physical morbidity
Physical dimensions
Physical problems—Weakness; inability or partial ability to sit, rise to standing, or walk; fatigue; pain; breathlessness; swallowing difficulties; incontinence; inability or partial ability to look after oneself
Sensory problems—Changes in vision or hearing; pain; altered sensation
Communication problems—Difficulties in speaking or using language to communicate; difficulties in writing
Social care or equipment needs—Mobility aids; transport; housing; benefits; employment; leisure
Non-physical dimensions
Anxiety, depression, and symptoms related to post-traumatic stress—New or recurrent somatic symptoms, including palpitations, irritability, and sweating; symptoms of derealisation and depersonalisation; avoidance behaviour; depressive symptoms, including tearfulness and withdrawal; nightmares; delusions; hallucinations; and flashbacks
Behavioural and cognitive problems—Loss of memory; attention deficits; sequencing problems; deficits in organisational skills; confusion; apathy; disinhibition; compromised insight
Other psychological or psychosocial problems—Low self esteem; poor or low self image and/or body image concerns; relationship difficulties, including those with the family and/or carer
During ward based care
For patients previously identified as being at low risk before discharge from critical care, perform a short clinical assessment to determine their risk of prolonged physical and non-physical morbidity (box 1).
For patients at risk:
Perform a comprehensive clinical reassessment to identify their current rehabilitation needs [Based on the GDG’s experience and opinion]
Offer an individualised, structured rehabilitation programme (delivered and supported by members of a multidisciplinary team) and incorporate the rehabilitation goals that had been set before discharge from critical care [Based on the GDG’s experience and opinion]
Consider offering a structured self directed rehabilitation manual3 when the patient’s physical and cognitive capacity allows, and support this for at least six weeks after discharge from critical care, coordinated by an appropriately skilled healthcare professional.
[All the above recommendations are based on a moderate quality randomised controlled trial]
For patients with symptoms of stress related to traumatic incidents and/or memories, refer to the NICE guideline on post-traumatic stress disorder.6 [Based on the GDG’s experience and opinion]
Before discharge to home or community care
Before discharging patients who are receiving individualised, structured rehabilitation during ward based care:
Perform a functional assessment that includes physical and non-physical dimensions (box 2)
Assess the impact of any impairment on activities of daily living and participation
Review, agree, and update the rehabilitation goals with the patient.
If continuing rehabilitation needs are identified ensure that before discharge:
Discharge arrangements, including appropriate referrals for the necessary continuing care, are in place
All discharge documents are completed and forwarded to the appropriate post-discharge services, primary care, and the patient.
[All the above recommendations are based on the GDG’s experience and opinion]
Two to three months after discharge from critical care
Review patients with previously identified rehabilitation needs two to three months after their discharge from critical care. Undertake a functional reassessment face to face in the community or in hospital; this should be performed by one or more appropriately skilled healthcare professionals familiar with the patient’s rehabilitation care pathway.
On the basis of the functional reassessment:
Refer the patient to the appropriate rehabilitation or specialist services if recovery seems slower than anticipated or if unanticipated physical and/or non-physical morbidity has developed
Give support if the patient is not recovering as quickly as they anticipated
If anxiety, depression, or post-traumatic stress disorder is suspected, follow the stepped care models recommended in the relevant NICE clinical guidelines.6 7 8
[All the above recommendations are based on the GDG’s experience and opinion]
Information and support
Provide support and information throughout rehabilitation as follows, sharing this information with the family and/or carer with the patient’s consent (or where the patient lacks capacity to give consent, involving the family and/or carer). [Based on high quality qualitative studies]
During the critical care stay
Provide information on their illness, treatments, equipment used, any possible short term and/or long term physical and non-physical problems. Give them the information more than once.
Before discharge from critical care
Explain the rehabilitation care pathway.
Explain the differences between critical care and ward based care and that the clinical responsibility will transfer to a different medical team.
Provide information on difficulties in sleeping, episodes of nightmares and hallucinations, and the readjustment to ward based care.
Before discharge to home or community
Provide information on physical recovery (based on the goals set) and how to manage activities of daily living.
Provide information on driving, returning to work, housing, and benefits, if applicable.
Provide information on local statutory and non-statutory support services.
Give the patient his or her own copy of the critical care discharge summary and rehabilitation plan.
Provide general guidance, especially to the family and/or carer, on what to expect and how to support the patient at home.
Overcoming barriers
Rehabilitation pathways for critical care patients may be complex, vary from place to place, and involve various professional groups, inpatient and community settings, and the crossing of traditional organisational boundaries. Thus, a fixed model of service delivery is not possible or practical, and responsibility for coordinating and delivering rehabilitation lies at the level of the organisation (acute and primary care trusts), rather than individual treatment teams. Hospital trusts will need to identify local solutions to the challenges set by this guideline. Importantly, this guideline spans the interface between primary and secondary care, requiring local agreement to ensure the recommended activity and communication across this boundary.
Secondary and primary care trusts may choose very different models of implementation depending on their existing service configuration, available assets, and commissioning structure.
Further information on the guidance
For many people, discharge from critical care is the start of an uncertain journey to recovery characterised by, among other problems, weakness, loss of energy, physical difficulties, anxiety, depression, post-traumatic stress, and for some a loss of cognitive function.9 Currently, rehabilitation strategies after a period of critical illness tend to be disease specific and served by neuroscience units, cardiac services, and stroke units. For general adult critical care patients who do not pass into the above specialist rehabilitation services, no widely available alternative rehabilitation pathway currently exists.
Methods
This guideline was developed as a short clinical guideline. Short clinical guidelines give recommendations on part of a care pathway and are intended to allow the rapid (over 9-11 months) development of guidelines for areas of care for which the NHS requires urgent guidance. Short clinical guidelines are developed by the NICE technical team using the same methodology as the existing standard NICE guidelines developed by the National Collaborating Centres (www.nice.org.uk).
As part of this process, the NICE technical team conducted a systematic search of the literature, assessed the quality of included studies, synthesised and presented the evidence using the modified grading of recommendations assessment, development, and evaluation (GRADE) system and checklists from the latest NICE guideline manual.10 The Guideline Development Group (comprising healthcare professionals and patient representatives) then discussed the evidence and drew up recommendations.
NICE has produced three different versions of the short clinical guideline: a full version, a quick reference guide, and a version for patients and the public. All versions are available on the NICE website.2
Further research
What is the most effective way of identifying patients at risk of physical and psychological morbidity and cognitive dysfunction associated with critical illness, and how can progression and response to interventions be monitored?
In patients at high risk, which therapeutic strategies are the most clinically and cost effective for reducing the prevalence and severity of physical and psychological morbidity and cognitive dysfunction associated with critical illness?
In patients with established morbidity, which specific therapeutic strategies are the most clinically and cost effective for reducing the magnitude of physical morbidity, psychological morbidity and cognitive dysfunction associated with critical illness?
For patients at high risk of morbidity associated with critical illness, what is the clinical effectiveness and cost effectiveness of organised critical care rehabilitation versus usual care on physical and psychological functioning, participation, and quality of life?
For those patients not identified as at high risk of morbidity associated with critical illness, what is the clinical effectiveness and cost effectiveness of organised critical care rehabilitation versus usual care on physical, psychological functioning, participation, and quality of life?
Notes
Cite this as: BMJ 2009;338:b822
Footnotes
This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The Guideline Development Group comprised Bipin Bhakta, Stephen Brett (chair), Nichola Chater, Brian Cuthbertson, Jane Eddleston, Melanie Gager, Peter Gibb, Karen Hoffman, Christina Jones, Amanda Lurie, David McWilliams, Dawn Roe, Amanda Thomas, Carl Waldmann, and Barry Williams. The NICE Short Clinical Guideline Technical Team comprised Lynda Ayiku, Kathryn Chamberlain, Ruth McAllister, Tim Stokes, and Toni Tan.
Contributors: TT drafted the summary, and SJB and TS reviewed the content.
Funding: The Centre for Clinical Practice (Short Clinical Guidelines Technical Team), part of the National Institute for Health and Clinical Excellence, wrote this summary.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
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