intergrated approach to management of patients

8/11/2019 Intergrated Approach to Management of Patients

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An integrated approach

to management ofcritically ill patients from

acute to community

Karen Hoffman

Clinical Specialist OTNeurosciences

Royal London Hospital


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Aim of project:

1. To identify the type of problems that patients mayhave during and after a critical care admission

2. To develop a protocol for Occupational Therapy

intervention, for patients admitted to an AdultIntensive Care Unit (ICU) and intervention possibleonce patients are transferred to the general wards andfollow up

3. To implement recommendations from nationalguidelines, i.e. NICE Head injury guidelines and theDepartment of Health Critical Care guidelines etc.


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Aim of project:

4. To contribute to BARTS and the London trust clinicalpathfinder, ensuring clinical effectiveness, patientexperience and clinical excellence

5. To make recommendations for further developmentof the ICU multidisciplinary follow-up clinic, includingthe use of reliable outcome measures and

implementation of the NSF for Long term conditionsand return to work


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Background of Critical Care

in the UK

Department of Health white paper 2000: ComprehensiveCritical CareA 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 ofillness 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 andcompassion to provide timely, safe and effective and efficientpatient-centred care (2005)


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Levels of critical care

Level 0: Normal acute ward care

Level 1:(General at risk

ward pts)

a) Acute ward care, with additional advice and

support from the critical care team eg

patients who are at risk of deterioration, orb) 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


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Outcome after ICUGriffiths and Jones 2002

A classification Tree for the outcomes after critical Care

ICU discharge

Hospital

discharge

28 days, 3 mth,

6mth, 1yr, 5yrs

General

Measures

Specific

Measures

Physical

Impairment

Functional

Status

Mental

Functions

Neuro-physiological

Functioning

Recovery

Cost

minimization

Cost

Benefit

Cost

effectiveness

Cost utility

Survival Quality of Life Functional

Outcome

Patients &

Relatives

Complications Adverse

Events

Case-mix

adjusted

performance

Staff

Economic

Evaluation

Society

Outcomes after

Intensive Care


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So what?

So why do OTs need to be involved

in critical care or

with patients that had a

life threatening experience?


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Brooks, Kerridge, Hillman,

Bauman and Daffurn, 1997

ICU patients, following discharge have

worse perceived heal th and m ore anx ietythan others in the commun ity. Sixty -three

per cent of pat ients had a poorer QOL

and func t ional heal th than those who

returned to ful l heal th and those in the

community.


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Delusional memories

of ICU

I remember that I was suppose to deliver some stolendiamonds for the mob. Somehow I lost them I dont knowhow.. but I knew that they were going to get me when theyfound out! I thought that Chucky you know, that doll

from the horror moviewas 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. Whilenearly all of the other patients seemed to have gotten betterand gone to the wards, I hadnt moved and didnt seem to

be getting any better. Then it dawned on methe nursesmust be using my blood to cure everyone else. Once theblood ran out, they would have no use for me, so I knew Iwas done for. I thought that one of the doctors would comeand slit my throat, and I was terrified


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Wu and Gao 2004

As soc iat ion of Anaesthet ists o f Great Br i tain & IrelandTraditional ICU short-term outcomes, e.g. length of stay

and mortality, although remaining extremely important,are not likely to be adequate surrogates for subsequentpatient-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 andintensive 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 socialinteractions into account. This has resulted in a moveaway from objective measures of critical care towardssubjective measures of functional status and quality oflife, with data collated directly from patients


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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 enablepeople to participate in the activities of every day life.

OTs achieve this outcome by enabling people to do thingsthat will enhance their ability to participate or by modifyingthe environment to better support participation


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Development of the protocol

While considering recommendations from national guidelines

1. OT models vs Health models

2. Literature searching3. Diagnosis, prognosis and outcome

4. Current ICU follow up clinics in the UK

5. International liaison with other OTs6. Outcome measures

7. Integrated approach for OT intervention

8. Competencies


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1. OT models vs Health

models


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Health Condition

(disorder/disease)

WHO ICF

Environmental

Factors

Personal

Factors

Body

function&structure

(Impairment)

Activities

(Limitation)

Participation

(Restriction)


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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


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WHO and Quality of life (QOL)

Health is a state of total physical, emotional andsocial well being and not merely the absence ofdiseases or infirmity.

Spilker (1996) suggested that QOL is amultidimensional concept comprising five majordomains: Physical status and functional abilities

Psychological status and well-being Social interactions

Economic and/or vocational status and factors

Religious and/or spiritual status


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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 afterICU

Quality of life and health outcome measures Environmental considerations, incl. AAC

Impact on and involvement of families


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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 andmyasthenia

Physical weakness

Muscle wasting due toperipheral neuropathy

Atrophy due to immobilisation

ROM / passive stretching

Acute psychological problems

Delusional Memories and PostTraumatic Stress Disorder

(PTSD)


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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 OTs Intervention

Capacity

Competencies


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6. Outcome measures

HRQOL

Depression and Anxiety

Functional (self care) Return to work

PTSD


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Society

Health condition (Diagnosis /

disorder)

Patients and

relatives

Functional outcome

Activity and

Participation

QOL, satisfaction

Staff

Return to work and

economical factorsCompetencies

/training

Environmental

Factors

Personal and

psychosocial factors

7. Integrated approach

for OT intervention


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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 movementupper

and lower limbs

Posture and seating

Communicative intent with

SLT

Functional independence

Control/ assess to

environment, i.e.

Environmental controls


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Summary and further

development

Audit of effectiveness of Protocol

OT competencies

Follow up clinic research

[email protected] [email protected]
mailto:[email protected]:[email protected]


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Resources

Department of Health websiteCritical care

Society for Critical Care MedicinePatient

and Family ResourcesAnasthesia and Intensive Care website

publications (http://www.aaic.net.au/)

Intensive Care After Care (Richard Griffiths and ChristinaJones, Butterworth Heineman Publishers, 2002)

intergrated approach to management of patients

Documents