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Rehabilitation and discharge 

Rehabilitation and discharge
Chapter:
Rehabilitation and discharge
Author(s):

Heather Baid

, Fiona Creed

, and Jessica Hargreaves

DOI:
10.1093/med/9780198701071.003.0021
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date: 25 September 2020

Psychological impact of critical care

The experience of being a patient in a critical care unit, along with the recovery period afterwards, may result in the development of significant psychological disorders, such as delirium, depression, anxiety, or post-traumatic stress disorder. Early identification and management of psychological problems will help to improve the patient’s quality of life and functional abilities after their recovery from critical illness.1 See Rehabilitation and discharge p. [link] for an overview of mental health assessment, Rehabilitation and discharge p. [link] for mental capacity assessment, and Rehabilitation and discharge p. [link] for non-physical dimensions of the critical care rehabilitation pathway.

Table 21.2 Non-physical dimensions5

Anxiety, depression, and post-traumatic stress-related symptoms

New or recurrent somatic symptoms, including palpitations, irritability, and sweating; symptoms of derealization and depersonalization; 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 organizational skills, confusion, apathy, disinhibition, compromised insight

Other psychological or psychosocial problems

Low self-esteem, poor or low self-image and/or body image issues, relationship difficulties, including those with the family and/or carer

Examples of strategies to help to reduce the psychological impact of critical care include patient diaries, follow-up clinics, support groups, and other online resources that involve sharing stories of patients’ experiences. All of these types of interventions may be therapeutic for some people in helping to reduce the psychological impact of being critically ill, but may be unhelpful for others if they provoke anxiety or remind them too much of the negative aspects of their critical care stay.

Patient diaries

  • These are used to help patients to make sense of their critical care experience and to reduce the psychological impact of critical illness on the patient’s recovery.1

  • There are a number of different types of diaries:

    • nurse led, with critical care nurses adding text and photos and facilitating the contribution of other healthcare professionals, family members, and patients to the diary

    • family led, with the family members taking full responsibility for the format and content of diary entries

    • patient led, if the patient is awake, well enough, and interested in keeping a diary

    • responsibility for the diary shared by healthcare professionals, family, and/or the patient.

  • The legal, ethical, and professional implications of diary use in the critical care setting must be explored before introducing diaries to a critical care unit.

Follow-up

  • Critical care outreach nurse follow-up on the ward after the patient has been discharged from the critical care unit.

  • Critical care follow-up clinic which provides the patient with an opportunity to discuss their physical and psychological recovery with someone from the critical care team and receive ongoing support after being discharged home.

  • There are a number of different types of critical care follow-up clinic:

    • nurse led by a critical care nurse and/or outreach nurse

    • physiotherapy led

    • medically led by an intensive care consultant

    • multidisciplinary in approach.

  • Community-based support such as that provided by the patient’s GP, psychologist, mental health team, occupational therapist, or social worker.

Support groups

  • Some patients find meeting up with other people who have experienced being a critically ill patient is a supportive experience that has a positive effect on their psychological recovery.

  • There are a number of different types of support group:

    • formal organizations (international, national, or local)

    • informal groups that meet in hospital or social settings on a regular or ad-hoc basis

    • patient-led groups, often with the involvement of family members of people who have been critically ill

    • healthcare professional-led groups, including regular support group meetings or one-off events (e.g. inviting service users to speak at a conference or teach students).

Online resources

  • Online support for patients can be found on the ICUsteps2 and Intensive Care Foundation3 websites.

  • A large collection of online video clips of patients talking about their critical care experience is freely available on the HealthTalkOnline4 website.

References

1 Jones C et al. Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised control trial. Critical Care 2010; 14: R168.Find this resource:

2 ICUsteps. Rehabilitation and dischargewww.icusteps.org

3 Intensive Care Foundation. Patients and Relatives. Rehabilitation and dischargewww.ics.ac.uk/icf/patients-and-relatives

4 HealthTalkOnline. Rehabilitation and dischargehttp://www.healthtalk.org/Intensive_care

Further reading

Peskett M and Gibb P. Developing and setting up a patient and relatives intensive care support group. Nursing in Critical Care 2009; 14: 4–10.Find this resource:

Rock LF. Sedation and its association with posttraumatic stress disorder after intensive care. Critical Care Nurse 2014; 34: 30–39.Find this resource:

Schandl AR et al. Screening and treatment of problems after intensive care: a descriptive study of multidisciplinary follow-up. Intensive and Critical Care Nursing 2011; 27: 94–101.Find this resource:

Wake S and Kitchiner D. Post-traumatic stress disorder after intensive care. British Medical Journal 2013; 346: f3232.Find this resource:

Williams SL. Recovering from the psychological impact of intensive care: how constructing a story helps. Nursing in Critical Care 2009; 14: 281–8.Find this resource:

Critical illness rehabilitation

Guidance for rehabilitation of patients who have been critically ill has been provided by NICE,5 and will be briefly summarized here (Tables 21.1 and Table 21.2 list the physical and non-physical dimensions to consider throughout the rehabilitation process). Rehabilitation should be started while the patient is still in the critical care unit, and continued on the ward and then at home after hospital discharge (see Figure 21.1 on Rehabilitation and discharge p. [link] for an overview of this rehabilitation care pathway continuum, and Rehabilitation and discharge p. [link] for further information about the psychological impact of critical illness).

Table 21.1 Physical dimensions5

Physical problems

Weakness, inability/partial ability to sit, rise to standing, or walk, fatigue, pain, breathlessness, swallowing difficulties, incontinence, inability/partial ability to self-care

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 and equipment needs

Mobility aids, transport, housing, benefits, employment and leisure needs


Figure 21.1 Rehabilitation care pathway.

Figure 21.1 Rehabilitation care pathway.

(Reproduced with permission from National Institute for Health and Care Excellence (2009) CG83 Rehabilitation after Critical Illness. London: NICE. Available from Rehabilitation and dischargehttp://guidance.nice.org.uk/CG83)

Key principles of care5

  • Ensure that the short-term and medium-term rehabilitation goals are reviewed, agreed, and updated throughout the patient’s rehabilitation care pathway.

  • Ensure the delivery of the structured and supported self-directed rehabilitation manual, if applicable.

  • Liaise with primary or community care for the functional assessment at 2–3 months after discharge from critical care.

  • Ensure that information, including documentation, is communicated as appropriate to any other healthcare settings.

  • Give the patient the contact details of the healthcare professional(s) on discharge from critical care, and again on discharge from hospital.

Information and support5

  • During the critical care stay, provide information about the patient’s illness, interventions and treatments, equipment used, and any short-and/or long-term physical and non-physical problems if applicable. This information should be communicated more than once.

  • Before the patient is discharged from critical care, or as soon as possible after their discharge from critical care, give them information about:

    • the rehabilitation care pathway, and, if applicable, emphasize the information about possible physical and non-physical problems

    • the differences between critical care and ward-based care, and the transfer of clinical responsibility to a different medical team

    • sleeping problems, nightmares, and hallucinations, and readjustment to ward-based care, if applicable.

  • Before the patient is discharged home or to the community, give them information about:

    • their physical recovery (based on the goals set, if applicable) and how to manage activities of daily living

    • diet and any other continuing treatments

    • driving, returning to work, housing, and benefits (if applicable)

    • local support services

    • general guidance for the family or carer about what to expect and how to support the patient at home.

  • Give the patient their own copy of the critical care discharge summary.

Reference

5 National Institute for Health and Care Excellence (NICE). Rehabilitation after Critical Illness. CG83. NICE: London, 2009. Rehabilitation and dischargewww.nice.org.uk/guidance/cg83 (Reproduced with permission.)

Further reading

Grap MJ and McFetridge B. Critical care rehabilitation and early mobilisation: an emerging standard of care. Intensive and Critical Care Nursing 2012; 28: 55–7.Find this resource:

Rehabilitation care pathway

Figure 21.1 shows the rehabilitation process as set out by the NICE guidelines on critical illness rehabilitation.6

Reference

6 National Institute for Health and Care Excellence (NICE). Rehabilitation after Critical Illness. CG83. NICE: London, 2009. Rehabilitation and dischargewww.nice.org.uk/guidance/cg83Find this resource:

Discharge from critical care

Discharge of a patient from critical care requires approval from the lead clinician (e.g. the critical care consultant), and should be considered as soon as the patient no longer requires critical care services. The patient should be fully ready for discharge and transferred out at an optimum time.

Potential adverse events resulting from unplanned discharge

  • Readmission to critical care.

  • Increased mortality.

  • Poor experience for the patient and their family.

Risk factors for unexpected negative outcomes of discharge

  • Discharge after 22.00 hours or at the weekend.

  • Premature discharge dictated by need for the bed, rather than by patient readiness.

  • Poor communication and teamworking within the critical care unit.

  • Poor communication and teamworking between the critical care unit and the ward.

  • Lack of critical care outreach or follow-up by critical care staff.

  • Lack of a step-down facility.

  • Initial illness severity.

Discharge process

  • Ensure that the patient has been discharged by the critical care team and remains ready for discharge (the area to which the patient is being discharged should be appropriate to the patient’s current Level of Care status).

  • Review the rehabilitation care pathway if one has already been started, and complete a short, comprehensive, or functional clinical assessment as appropriate (see Rehabilitation and discharge p. [link]).

    • Identify the patient’s current physical and non-physical health needs and specific treatments to be continued after discharge from critical care.

    • Identify risk factors for deterioration and preventive measures.

  • Confirm that the area to which the patient is being discharged is ready for the patient and will be able to safely provide all aspects of the patient’s health needs. Special considerations include:

    • pain management—PCA, epidural

    • tracheostomy

    • enteral or parenteral feeding

    • IV therapy

    • wounds, drains, or ostomies.

  • Provide discharge education and psychological support for the patient and their family (for a discussion of the patient-centred discharge approach, see Rehabilitation and discharge p. [link]).

  • Prepare the patient, equipment, medications, and documentation according to local practice and protocols.

  • Refer the patient to other services as appropriate (e.g. critical care outreach, site manager, physiotherapist, occupational therapist, speech and language therapist, dietitian, social worker).

  • Transfer the patient out of critical care, providing a systematic handover to the nurse taking over care of the patient.

Patient-centred discharge

  • Involve the patient and their family throughout the decision-making process in relation to discharging the patient from critical care.

  • Provide reassurance and support for the patient and their family before, during, and after discharge.

  • If the patient remains in critical care due to a lack of available ward beds, do not continue to provide Level 3 care. For example:

    • Care for the patient according to their current level of acuity.

    • Stop unnecessary continuous monitoring, such as ECG, arterial blood pressure, and CVP monitoring.

    • Monitor observations as frequently as would be done on the ward for the patient’s current status.

    • Encourage the patient to be as independent as possible with regard to personal hygiene needs and eating and drinking.

    • Encourage mobilization as appropriate for the patient’s condition.

  • Provide the patient with a patient discharge summary written in a way that the patient and family can easily understand, using lay terminology.7,8

    • Delirium and memory loss during the critical care stay can cause distress and impede psychological recovery after discharge. A patient discharge summary may help the patient to understand what happened to them during their critical care stay.

    • White and colleagues9 have provided a freely available online discharge summary training resource for critical care healthcare professionals, which also includes a patient discharge summary template.

References

7 Bench S, Day T and Griffiths P. The effectiveness of written and/or verbal critical care discharge information to support early critical illness recovery: a narrative critical review. Critical Care Nurse 2013; 33: 41–52.Find this resource:

8 Bench S et al. Providing critical care patients with a personalized discharge summary: a questionnaire survey and retrospective analysis exploring feasibility and effectiveness. Intensive & Critical Care Nursing 2014; 30: 69–76.Find this resource:

9 White C, Bench S and Hopkins P. Critical Care Patient Discharge Summary Training Pack. Rehabilitation and dischargewww.icusteps.org/assets/files/ccpatient-discharge-pack.pdf