Intensive and Critical Care Nursing
Volume 24, Issue 4 , Pages 209-210, August 2008

Improving rehabilitation following transfer from ICU

  • Carol Ball

      Affiliations

    • Royal Free Hampstead NHS Trust, Pond St, London NW3 2QN, United Kingdom
    • City Community and Health Sciences, City University, Northampton Square, London EC1V 0HB, United Kingdom
    • Corresponding Author InformationCorrespondence address: Royal Free Hampstead NHS Trust, Pond St, London NW3 2QN, United Kingdom.

Article Outline

 

The need for support and rehabilitation following critical illness is well documented in the literature (Williams and Leslie, 2008) and now features on the internet (www.i-canuk.co.uk). In particular problems are associated with functional disability (O’Brien et al., 2004, Van der Schaaf et al., 2004), neuromuscular weakness (Latronico et al., 2005, De Jonghe et al., 2002), and cognitive impairment (Hopkins and Jackson, 2006, Pandharipande et al., 2005, Ely et al., 2004). Disability, in the guise of neuromuscular weakness and cognitive impairment, has been associated with multiple organ failure, multi-trauma, severe infections, the use of corticosteroids and paralysing agents (Visser, 2006). In some patients bone hyperresorption is evident due to Vitamin D deficiency that usually associated with advanced age, prolonged hospitalisation with lack of exposure to sunlight, inadequate nutritional support and multiple medical problems (Nierman and Mechanick, 1998).

However, there are few studies that identify interventions which may aid recovery (Elliott et al., 2006, Jones et al., 2003) and only one of these addresses interventions during hospitalisation (Jones et al., 2003). Yet the European Society for Physical and Rehabilitation Medicine recommends rehabilitation should occur as early as possible, even within the intensive care unit (Gutenbrunner et al., 2006). Rehabilitation is defined as ‘a process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimal physical, psychological and social function’ (Gutenbrunner et al., 2006: 295).

Prolonged, untreated disability also places a burden on the health economy. In the acute sector length of stay is increased. In primary care costs are associated with institutional accommodation, carer allowances and the treatment of complications associated with immobility such as pain, incontinence, communication disorders, mood and behavioural disorders (Gutenbrunner et al., 2006). It has been argued that rehabilitation is less expensive than providing no such service (Bent et al., 2002).

We, working in intensive care units, should actively promote rehabilitation and demonstrate this through the improved collaboration of nurses, respiratory physiotherapists, neuro physiotherapists, speech and language therapists, dieticians and occupational therapists. Specific outcomes for this group could be earlier mobilisation out of bed, earlier vocalisation in appropriate patients and earlier tracheostomy weaning.

Currently, only rarely, is a specific multi-disciplinary goal-directed rehabilitation programme identified for patients transferred to the ward from intensive care. A number of therapists are engaged in their management but this is usually at the request of the medical/surgical team who necessarily focus on the disease process rather than rehabilitation. It is also characterised by communication via the patients’ notes rather than team discussion and coordination. It is recognised that the provision of therapy services for patients transferred from the ICU is not coordinated and should be for rehabilitation to be effective. This has also been noted by patients in the literature (Strahan and Brown, 2004).

This lack of coordination between members of the multi-disciplinary team needs to be addressed. Is it time to consider the rehabilitation multi-disciplinary team being allocated to the patient, rather than to a specific ward or specialty, with specific lines of responsibility and accountability established for goals being met? It certainly is an area for more research, particularly that related to interventions and their success or otherwise. However, research studies always take some considerable time to set up and achieve funding. Thus, would it be more timely to undertake a review of a patient's ‘journey’ post discharge from your particular intensive care unit, identify the gaps in service provision and set up one goal oriented intervention that might improve the coordination of services leading to safer and more effective rehabilitation? Guidelines for help with these small cycles of change can be found on the Institute for Health Improvement website (www.ihi.org). For our part, as a journal which increasingly receives manuscripts from other health professionals as well nurses, we would welcome submissions on this issue as small scale service improvement articles or research studies. Resources in the pursuance of excellence in this area are limited and Intensive and Critical Care Nursing is committed to their dissemination.

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References 

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PII: S0964-3397(08)00035-9

doi:10.1016/j.iccn.2008.04.001

Intensive and Critical Care Nursing
Volume 24, Issue 4 , Pages 209-210, August 2008

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