ICU and Beyond – Establishing a Post ICU Rehabilitation Pathway and Virtual Class

Purpose

Within our consultant led ICU follow up clinic we recognised that there were an increasing number of patients presenting with on-going physical and psychological problems relating to their stay. Many of these patients reported lack of access to longer term rehabilitation and psychological support.

The purpose was to develop a specialist therapy pathway for patients following an intensive care stay; to improve physical and psychological outcomes, and the overall experience and support for patients and families.

Aspects included working towards;

  • Specialist Supported discharge home.
  • Joint handover of care and on-going support to community teams
  • 3 month review in line with NICE guidance.
  • Provision of MDT rehab class.
  • Capacity to provide hydrotherapy in the future.
  • Development of MDT follow up clinics
  • Psychology support with specific reference to ICU and critical illness

Beyond – Establishing a Virtual Post ICU Rehabilitation Class

 

The COVID-19 pandemic forced us to rethink how we could deliver Post ICU support and ensure rehabilitation needs of those leaving ICU were met.

The redeployment of staff during the first wave allowed us to pilot a virtual Post ICU rehabilitation class.

35%
patients seen within 24 hours of ICU discharge

Average improvement of 5.75
on 30 second STS
Qualitative feedback from patients
was very positive in terms of patient experience.

Approach

We used a test of change approach to provide follow up therapy on the wards and supported discharge to home as our caseload allowed. We prioritised Level 3 ICU patients who had a prolonged ICU stay and had extensive rehabilitation needs.

Early communication with the community rehabilitation teams was important. The critical care team aimed to review the patient at home within 48 hours of discharge. A joint handover of care would happen with the community team when they had capacity.

Patients were identified for the pilot virtual class via:

  • Follow up clinic
  • ICU COVID-19 caseload
  • Patients who received ICU supported discharge in 2020 prior to pandemic and had on-going rehab needs.

6 out of 9 patients consented to join the class. A Standard operating procedure which included an inclusion and exclusion criteria was implemented. We set up a generic ICU rehab email to communicate with patients.

Class Set Up:

  • Pre/Post assessments on Attend Anywhere or Telephone.
  • Virtual class on Zoom – X2 week for 6 week cohort
  • 1 hour class:  ½ hour exercise; ½ hour education.
  • MDT education to support Post ICU recovery

Outcomes

This test of change was carried out prior to the COVID-19 pandemic within existing resource and as ICU commitments and staffing allowed. Despite these limitations, the team successfully supported 33 patients and saw a reduction in overall LOS from 21 to 19 days. The waiting time to be seen by the community team ranged from 2-6 weeks. Time from ICU discharge to follow up was

  • 35% patients within 24 hours
  • 35% patients within 48 hours
  • 19% patients within 5 days
  • 11% patients after 5 days.

Qualitative feedback from patients was very positive in terms of patient experience.

 

When setting up the virtual class It was important that a range of outcome measures were used to capture both the physical and psychological effects of critical illness, and to support future funding applications.

The measures used included:

  • The Fatigue Assessment Scale (FAS).
  • The Generalised Anxiety Disorder -7 Assessment (GAD-7), The Patient Health Questionnaire – 9 (PHQ-9).
  • The EQ5D5L Measure of Quality of life.
  • The 30 Second Sit to Stand (STS) test was used as a physical outcome measure. This was thought to be the best tool to assess strength and endurance remotely.
  • The Medical Research Council (MRC) dyspnoea scale was used to assess on-going breathlessness.

 

All participants demonstrated improvements across all outcome measures. Perhaps the most significant results were seen in the EQ5D5L .

Please see the attached Innovations poster under 'Additional Notes' below.

 

The 30 second STS chart shows an average improvement of 5.75. An increase in 5 at post assessment is clinically significant.

 

A patient focus group was held to gain feedback from patients and families regarding their experiences of leaving critical care and managing the class; to direct future pathway developments.

Our quality improvement team extracted themes from the focus group;

  • “Nice to share experiences with others in similar positions”
  • “Without the class online I would not have been able to attend”
  • “It feels more 1:1, it's a lot more personal!”
  • All patients said they “felt better after the classes”
  • "Follow up has been absolutely fantastic"
  • 5 out of 6 patients would choose virtual over face to face again.

Cost and savings

A zoom account for the Pilot cost was £14.39 per month.

A business case has since been created to secure funding to sustain this work.

Implications

Research on the longer-term consequences of critical illness has shown that a high proportion of patients surviving critical illness have significant, continuing problems. For many, discharge from critical care is the start of an uncertain journey to recovery characterised by weakness, loss of energy, physical difficulties, anxiety, depression, post-traumatic stress (PTS), phenomena and, for some, impaired cognitive function (NICE 2009).

It is widely recognised that development of specialist ICU follow up services is required. The Covid 19 pandemic will mean many more patients will have complex rehabilitation needs upon discharge and structured and joined up rehabilitation pathways, with an understanding of the patients critical care journey will be vital.

Top three learning points

  1. Patient and family involvement has been instrumental in shaping how we provide future services. Providing the right care, at the right time, with the right delivery.
  2. The continuity of care for the patient from admission to ICU through to Discharge home has shown to be effective at not only reducing LOS but also improving patient and family experience.
  3. This model of care has worked well for a small District General Hospital; considerations need to be made on which aspects of the project could be applied to larger Intensive care units.

Fund acknowledgements

Work was unfunded.

Additional notes

Please see the attached Innovations poster below.

For further information about this work please contact Lisa Bashford