Sequelae and rehabilitation after critical illness

Rehabilitation while in intensive care

Research from surveys, cohort studies and randomised controlled trials (RCTs) relates to a range of different types of rehabilitation strategies for patients with critical illness during their intensive care unit (ICU) stay:

• Physical- and physiotherapy-based interventions include the use of various respiratory manoeuvres to improve ventilation and clear secretions, use of a tilt table, stretches, passive and assisted exercises, transfers, mobilisation and walking on the spot.^8,9

• Early mobilisation in 103 patients with respiratory failure who received early activity as part of routine respiratory ICU care was found to be feasible and safe.¹⁰

• The use of a mobility team (critical care nurse, nursing assistant and physical therapist) and a mobility protocol resulted in decreased ICU and hospital stays in the intervention group (n=165) compared with usual care (n=165); the introduction of this early intervention was also reported to be safe.¹¹

• Supervised physical training during ICU improved muscle strength and functional status, and also increased ventilator-free time in the treatment group (n=20) compared with the control group (n=19).¹²

• The use of patient diaries has been proposed as a method of reducing non-physical sequelae associated with critical illness. In a large study of 352 patients recovering from critical illness, patient diaries helped psychological recovery and reduced post-traumatic stress disorder (PTSD) particularly in those with higher PTSD scores.¹³

• A multicomponent rehabilitation intervention of interrupted sedation together with physiotherapy and occupational therapy in ventilated patients reported earlier return to independent functional status at hospital discharge, shorter duration of delirium and more ventilator free days in the treatment group (n=49) compared with the control group (n=55).¹⁴

These examples of rehabilitation interventions during ICU highlight the importance and potential for interventions which could improve the outcome for patients in the early stages after critical illness.

Rehabilitation after the intensive care unit and hospital discharge

There is a paucity of literature to support rehabilitation following discharge from intensive care, particularly following discharge from hospital. It is also unclear what components should be included in this rehabilitation. Evidence of benefit for follow-up clinics is lacking and they are not routine practice. Their components are diverse and do not necessarily include important elements of rehabilitation which would target the physical and non-physical sequelae (Table 1).¹⁵

Clinical implications

The 2009 NICE guidelines for rehabilitation after critical illness recommend a stepwise approach to rehabilitation through the different stages of critical illness using a screening and assessment process to target those most likely to benefit:⁴

• the critical care stay

• ward-based care

• after discharge from hospital.

This process encompasses a transition of the focus of care from ICU-led survival management towards rehabilitation delivered by a skilled multidisciplinary team (MDT), which includes the physician, and which can offer holistic care to patients with complex problems. It is important for physicians to help identify any physical and non-physical sequelae that develop at each stage and refer patients to appropriate services and to other members of the MDT. Access to other relevant team members and resources is important. It may be helpful to have a designated healthcare professional(s) to co-ordinate the rehabilitation process to ensure that all aspects of care are addressed:

• screening and assessment

• provision of rehabilitation

• access to welfare and benefits

• provision of information and contact details

• guidance for carers on how to support the patient after discharge.

A short clinical assessment at each stage of critical illness should identify risk for sequelae in all patients (low vs high risk) by considering pre-existing risk factors and asking about any new change in status, for example:

• reduced physical function and ability to perform activities of daily living (ADL)

• respiratory problems

• weight loss/gain

• pain

• difficulty sleeping

• anxiety and panic

• intrusive memories.

Comprehensive clinical assessment

If the risk for sequelae is high, recovery slower than expected or unanticipated sequelae have developed, there should be a comprehensive clinical assessment and referral for rehabilitation.

This should include assessment of the impact of any functional limitations on the patient's ADL, identification of the patient's rehabilitation needs, as well as identification of any other issues, for example:

• sensory, nutritional and communication problems

• psychological issues

• new symptoms of delusions, anxiety, panic and depression.⁴

While very few evidenced-based screening tools are available, MDT members are familiar with a range of questions and outcome measures which can be used to gain a comprehensive assessment and identification of realistic patient goals. They also have access to further guidance relating to screening, assessment and management of many other sequelae such as PTSD, delirium, anxiety and depression.^25–28

Assessment on the ward of a patient at high risk for sequelae after critical illness could include, for example:

• the use of skilled questioning⁴

• assessment of function with the Rivermead Mobility Index²⁹

• assessment of delirium using the confusion assessment method (short confusion assessment method (CAM))³⁰

• anxiety and depression using HADS³¹

• pain and fatigue using a visual analogue scale³²

• screening for malnutrition using the Malnutrition Universal Screening Tool (MUST).^33,34

This highlights the need for access to a range of health professionals to complete a comprehensive assessment and then deliver an appropriate individualised rehabilitation package to counteract the sequelae and support the return of activity and QoL levels similar to those experienced before the critical illness.

Research implications

Further research is needed to develop simple and effective methods to screen and identify patients at risk of developing sequelae following critical illness. The development of feasible, effective and sustainable rehabilitation interventions for the management of such sequelae following critical illness particularly requires further research. Evaluation of this complex intervention will involve an iterative process in order to determine the important characteristics such as the target population, the essential rehabilitation components, optimal timing for commencement of the intervention, the intensity, amount of supervision, duration and follow-up, all of which could contribute to improved patient outcomes.

A few different interventions have been investigated (Table 2). It is difficult to determine whether it is more important to study first the effects of a single component (eg exercise) or encompass multiple components, for example a rehabilitation intervention which includes physical, psychosocial and education elements, and involves patients and carers.

As this research is in its infancy, the inclusion of a process evaluation would be important.³⁵ Some studies using qualitative methods have provided valuable insights into the physical and psychological experiences of patients following transfer from the ICU. However, translating these findings into a feasible and acceptable intervention with patient-centred outcome measures requires further work. An economic evaluation would also be appropriate. It is anticipated that the results from ongoing and future trials (Table 2) will add to the evidence on rehabilitation after critical illness and inform clinical practice and implementation.