An integrated approach to management of critically ill patients from acute to community

1. An integrated approach to management of critically ill patients from acute to community Karen Hoffman Clinical Specialist OT Neurosciences Royal London Hospital

2. Aim of project: • To identify the type of problems that patients may have during and after a critical care admission • To develop a protocol for Occupational Therapy intervention, for patients admitted to an Adult Intensive Care Unit (ICU) and intervention possible once patients are transferred to the general wards and follow up • To implement recommendations from national guidelines, i.e. NICE Head injury guidelines and the Department of Health Critical Care guidelines etc.

3. Aim of project: • To contribute to BARTS and the London trust clinical pathfinder, ensuring clinical effectiveness, patient experience and clinical excellence • To make recommendations for further development of the ICU multidisciplinary follow-up clinic, including the use of reliable outcome measures and implementation of the NSF for Long term conditions and return to work

4. Background of Critical Care in the UK • Department of Health white paper 2000: “Comprehensive Critical Care – A review of Adult Critical Care services.” • “Comprehensive critical care is not simply a new name for intensive care, but is a new approach based on severity of illness and long term outcome.” • ICS, ESICM, Scottish Intensive care, SCCM (USA) • vision for critically ill and injured patients – • integrated teams of dedicated experts • directed by trained and present intensivist physicians. • Multi professional teams use knowledge, technology and compassion to provide timely, safe and effective and efficient patient-centred care (2005)

5. Levels of critical care

6. Outcome after ICU Griffiths and Jones 2002

7. So what? So why do OT’s need to be involved in critical care or with patients that had a life threatening experience?

8. Brooks, Kerridge, Hillman, Bauman and Daffurn, 1997 “ICU patients, following discharge have worse perceived health and more anxiety than others in the community. Sixty-three per cent of patients had a poorer QOL and functional health than those who returned to full health and those in the community.”

9. Delusional memories of ICU “I remember that I was suppose to deliver some stolen diamonds for the mob. Somehow I lost them… I don’t know how.. but I knew that they were going to get me when they found out! I thought that ‘Chucky’ – you know, that doll from the horror movie – was going to come and kill me! Later, when I realised where I was, I noticed that the nurses seemed constantly to be taking blood out of my arm. While nearly all of the other patients seemed to have gotten better and gone to the wards, I hadn’t moved and didn’t seem to be getting any better. Then it dawned on me – the nurses must be using my blood to cure everyone else. Once the blood ran out, they would have no use for me, so I knew I was done for. I thought that one of the doctors would come and slit my throat, and I was terrified”

10. Wu and Gao 2004Association of Anaesthetists of Great Britain & Ireland “Traditional ICU short-term outcomes, e.g. length of stay and mortality, although remaining extremely important, are not likely to be adequate surrogates for subsequent patient-centred outcomes.” “As such, the global ICU outcomes should incorporate not only short-term outcomes but also long-term outcomes, which focus specifically on how critical illness and intensive care affects a patient's and/or relatives' long-term health and psycho-social well-being.” “Long-term outcomes particularly take the follow-up, physical, psychological, functional status and social interactions into account. This has resulted in a move away from objective measures of critical care towards subjective measures of functional status and quality of life, with data collated directly from patients”

11. Role of OT in Critical care: WFOT definition of OT: “A profession concerned with promoting health and wellbeing through occupation. The primary goal of Occupational Therapy is to is to enable people to participate in the activities of every day life. OT’s achieve this outcome by enabling people to do things that will enhance their ability to participate or by modifying the environment to better support participation”

12. Development of the protocol While considering recommendations from national guidelines… • OT models vs Health models • Literature searching • Diagnosis, prognosis and outcome • Current ICU follow up clinics in the UK • International liaison with other OT’s • Outcome measures • Integrated approach for OT intervention • Competencies

13. 1. OT models vs Health models

14. Body function&structure(Impairment) Activities (Limitation) Participation (Restriction) Environmental Factors Personal Factors WHO ICF Health Condition (disorder/disease)

15. Activity and participationProductivity, leisure, self maintenance, psychological Considerations of the NSF for LTC (Qr 3-7) • Early and specialist rehabilitation • Impact on the family • Psychological implications and QOL • Vocational Rehabilitation • Self maintenance / self care • Fatigue

16. WHO and Quality of life (QOL) • Health is a state of total physical, emotional and social well being and not merely the absence of diseases or infirmity. • Spilker (1996) suggested that “QOL is a multidimensional concept comprising five major domains: • Physical status and functional abilities • Psychological status and well-being • Social interactions • Economic and/or vocational status and factors • Religious and/or spiritual status”

17. 2. Literature searching Themes / key words: • Rehabilitation interventions (early and long term rehab) and outcome following critical care (cognitive, functional and psychological) • Occupational Performance during and after ICU • Quality of life and health outcome measures • Environmental considerations, incl. AAC • Impact on and involvement of families

18. Sepsis Multi organ failure Neurological problems Poly trauma Respiratory failure Acute Respiratory Distress Syndrome (ARDS) Cardiac failure General surgery Neuromuscular problems - Critical illness polyneuropathy Demyelinating disease Neuromuscular junction and myasthenia Physical weakness – Muscle wasting due to peripheral neuropathy Atrophy due to immobilisation ROM / passive stretching Acute psychological problems Delusional Memories and Post Traumatic Stress Disorder (PTSD) 3. Diagnosis, prognosis and outcome

19. 4 & 5 Follow up clinics and international OT practice 4. Current ICU follow up clinics in the UK • Intervention • Outcome measures • Team members 5. International liaison with other OT’s • Intervention • Capacity • Competencies

20. 6. Outcome measures • HRQOL • Depression and Anxiety • Functional (self care) • Return to work • PTSD

21. Society 7. Integrated approach for OT intervention Health condition (Diagnosis / disorder) Patients and relatives Functional outcome Activity and Participation QOL, satisfaction Staff Return to work and economical factors Competencies/training Environmental Factors Personal and psychosocial factors

22. Structure of clinical reasoning tool:

23. Summary and further development • Audit of effectiveness of Protocol • OT competencies • Follow up clinic research Karen.hoffman@thpct.nhs.uk or karennaude@hotmail.com

24. Resources • Department of Health website – Critical care • Society for Critical Care Medicine – Patient and Family Resources • Anasthesia and Intensive Care website – publications (http://www.aaic.net.au/) • Intensive Care After Care (Richard Griffiths and Christina Jones, Butterworth Heineman Publishers, 2002)