an integrated approach to management of critically ill patients from acute to community karen...
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An integrated approach to management of critically ill patients from acute to community
Karen HoffmanClinical Specialist OT
NeurosciencesRoyal London Hospital
Aim of project:
1. To identify the type of problems that patients may have during and after a critical care admission
2. 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
3. To implement recommendations from national guidelines, i.e. NICE Head injury guidelines and the Department of Health Critical Care guidelines etc.
Aim of project:
4. To contribute to BARTS and the London trust clinical pathfinder, ensuring clinical effectiveness, patient experience and clinical excellence
5. 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
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)
Levels of critical care
Level 0: Normal acute ward care
Level 1:(General at risk ward pt’s)
a) Acute ward care, with additional advice and support from the critical care team eg patients who are at risk of deterioration, or
b) Who are recovering after higher levels of care and still have great nursing needs
Level 2:(High Dependency)
Detailed observation or intervention eg patients with a single failing organ system, or post-operative patients, or patients stepping down from higher levels of care
Level 3:(Intensive Care)
Advanced respiratory support alone, or basic respiratory support together with support of at least two organ systems
Outcome after ICU Griffiths and Jones 2002
A classification Tree for the outcomes after critical Care
ICU d ischarge
Hospitald ischarge
28 days, 3 m th ,6m th, 1yr, 5yrs
GeneralMeasures
SpecificMeasures
PhysicalIm pairm ent
FunctionalStatus
Menta lFunctions
Neuro-physiologicalFunction ing
Recovery
Costm in im ization
CostBenefit
Costeffectiveness
Cost u tility
Survival Q uality o f L ife FunctionalO utcom e
Patients &Relatives
C om plications AdverseEvents
C ase-m ixadjusted
perform ance
Staff
Econom icEvaluation
Society
Outcom es afterIn tensive Care
So what?
So why do OT’s need to be involved
in critical care or
with patients that had a
life threatening experience?
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.”
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”
Wu and Gao 2004
Association 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”
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”
Development of the protocol
While considering recommendations from national guidelines…
1. OT models vs Health models
2. Literature searching
3. Diagnosis, prognosis and outcome
4. Current ICU follow up clinics in the UK
5. International liaison with other OT’s
6. Outcome measures
7. Integrated approach for OT intervention
8. Competencies
1. OT models vs Health models
Health Condition Health Condition ((disorder/diseasedisorder/disease))
WHO ICF WHO ICF
Environmental Environmental FactorsFactors
Personal Personal FactorsFactors
Body Body function&structurefunction&structure
(Impairment(Impairment))
ActivitiesActivities(Limitation)(Limitation)
ParticipationParticipation(Restriction)(Restriction)
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
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”
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
3. Diagnosis, prognosis and outcome
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)
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
6. Outcome measures
HRQOL Depression and Anxiety Functional (self care) Return to work PTSD
Society
Health condition (Diagnosis / disorder)
Patients and relatives
Functional outcomeActivity and ParticipationQOL, satisfaction
Staff
Return to work and economical factors
Competencies/training
Environmental Factors
Personal and psychosocial factors
7. Integrated approach for OT intervention
Structure of clinical reasoning tool:
Assessment / issue: Intervention Outcome measure Equipment
Level of arousal / awareness post weaning off sedation
SMART Ax, Task analysis, establish cause and effect
Pen light, written & verbal instructions, taste and smell stimuli
Visual assessment Visual rehabilitation- focus scanning, tracking, occulo- motor control
Consistent visual response on task analysis sheet & ability to scan
Pen light, letter chart, 2 and 3D items etc
Assessment of tone / spasticity
Medication, positioning and orthotics, facilitated tasks (Bobath), casting, 24hour positioning programme
Increase function (Modified Ashworth Scale), ROM, MS
Thermoplastics, casting material, functional tasks
Range of movement – upper and lower limbs
Posture and seating
Communicative intent with SLT
Functional independence
Control/ assess to environment, i.e. Environmental controls
Summary and further development
Audit of effectiveness of Protocol OT competencies Follow up clinic research
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)