Development of a Multidisciplinary Post Critical Care Clinic at Guy’s & St Thomas’ NHS Foundation Trust

The health burden attributable to impaired recovery from critical illness is substantial. Recently there has been increasing recognition of and commitment to address the physical, psychological and cognitive components which make up (PICS).

Of the 80% of patients discharged from critical care alive, approximately 50% suffer with one or more components of PICS. The overall mission of our project is to complete a thorough assessment of intensive care survivors using the expertise of the MDT to evaluate and identify key clinical features associated with PICS. We then co-ordinate the implementation of key primary and secondary care services to improve the recovery of these patients. We recognise that by improving aftercare of these patients the impact of critical illness on family is also improved.

We appreciated the need to elevate the quality of critical care aftercare at GSTFT to the same first class level as that provided within the acute inpatient care. We see approximately 200 new patients per year. The service has been commissioned since May 2016.

Primary objectives:

• Identify features of PICS by performing a multidisciplinary thorough functional assessment.
• Co-ordinate aftercare using primary and secondary care services to accelerate recovery from PICS.
• Implement relevant recommendations from NICE CG83 (statements 1.23, 1.24, 1.25).

Secondary objectives:

• Address complex medical issues and long term conditions
• Take on a clinical safety-netting and coordinating role for patients and family
• Decode and understand patients’ critical care experience Improve lived experience of critical illness recovery
• Signpost social, financial, welfare advice
• Liaise with primary care practitioners
• Evaluate sexual function and quality of sleep
• Provide expert advice regarding air travel and driving.

Tertiary objectives:

• Improve within-unit clinical care and patient experience
• Deliver learning and feedback for all staff
• Collect patient data and operational data to monitor governance and performance.

*In addition to implementing the NICE CG83 recommendations, we also sought to apply the guidance and recommendations from the Guidelines for the Provision of Intensive Care Services (GPICS) document (published jointly by the Faculty of Intensive Care Medicine and the Intensive Care Society) which specifies that discharged patients should have access to a critical care follow-up clinic (GPICS section 3.1.4, standard 2.16) and makes a number of recommendations.

GSTFT Critical Care has an international reputation for clinical excellence. As well as serving the local population of Lambeth and Southwark we provide tertiary critical care to a wide region in the South of England.

Our case mix is challenging with a large proportion of complex medical, surgical, vascular and cardiothoracic patients. We manage a wide spectrum of medical and surgical emergencies from the emergency department, wards, theatres and external referrals from other Trusts. This includes the nationally-commissioned severe respiratory failure service which provides extracorporeal membrane oxygenation (ECMO) to the South of England and beyond.

We admit ~2200 patients per year. Our patients are at high risk of PICS in view of their complexity and severity of illness. PICS is defined as impairment of cognition, mental health and physical function in survivors of critical illness. The consequences of PICS include reduced quality of life, reduced physical functioning and delay or inability to resume work.

According to NICE CG83 (recommendations 1.23 to 1.25), patients should receive a review of rehabilitation, health and social needs two to three months following discharge from critical care. This should comprise a functional assessment of physical and non-physical sequelae of critical illness and provision of support where needed.

However in 2014 under a third of UK critical care units reported having critical care follow-up. At GSTFT we recognised a discrepancy between (a) the first class quality of care delivered during the acute phase, including delivery of high intensity inpatient rehabilitation and (b) the lack of follow-up and aftercare of our patients after discharge from hospital.

We noted that many of our patients are regionally referred and therefore get repatriated to their referring hospitals after critical care step down. We had no way of ensuring follow up care for these patients and no funding identified for this purpose. In 2015 this gap in our service at GSTFT was re-visited.

An analysis concluded that up to 700 of our discharged patients might benefit from an assessment of PICS, while the number meeting criteria for a face-to-face specialist follow up clinic might reach 150 or 200 annually. We set out to address the recommendations in NICE CG83 relevant to post critical care follow-up, and this led to the development and piloting of a post critical care follow-up clinic at GSTT in April 2015. The service evolved as below.

This service has evolved over two years from a pilot into a fully-commissioned and comprehensive MDT service, funded by the local CCG. It is a secondary care clinic, which takes place in hospital outpatient setting, led by intensive care consultant. During the pilot phase, patients were seen at 2-3 months following discharge in an ad hoc Friday morning clinic led by an intensive care consultant, nurse and physiotherapist (all unpaid).

The team expanded in response to patient need to include access to a dietician, an occupational therapist, psychology assistant and a second consultant. A local GP was invited to attend the clinic to advise regarding optimal engagement with primary care and community services. The service was designed and shaped according to the following elements:

• NICE CG83
• GPICS
• Patient feedback
• Accumulated experience of both consultants.

The pilot phase clinic showed early signs of success on the grounds of feasibility, positive patient feedback, and identification of numerous potentially-modifiable physical and non-physical features of PICS. Data collection for the pilot included: (a) patient experience data via detailed feedback questionnaire, (b) clinical data ie: prevalence of modifiable PICS (gleaned from in-clinic assessments and number of required referrals), and (c) operational/feasibility data (duration of consultations, staff time required, space needed etc). Approximately 35 patients were assessed in the first 9 months. A sustainable model would require a funding stream and dedicated resources.

In early 2016, a business case was submitted for a new outpatient multidisciplinary service for intensive care survivors to the local clinical commissioning group (CCG). Our stated mission was to improve recovery for intensive care survivors with PICS (physical, cognitive, psychological impairment). We envisaged that this would be best done via a fully assembled multidisciplinary consultant-led team, mirroring the breadth of expertise available within the critical care units but translating this to the outpatient rehabilitation setting to provide coordinated care.

The team would comprise:

• Critical Care Consultant
• Critical Care Nurse
• Nursing Assistant
• Physiotherapist
• Occupational Therapist
• Clinical Psychologist
• Neuropsychiatrist
• Dietician
• Pharmacist

Funding was successfully awarded in May 2016. The per-patient funding model covers face-to-face consultations with the various providers listed above (excepting dietician, pharmacist which are delivered by telephone). A small amount of secretarial support has been made available. In the last 12 months, activity has grown significantly to necessitate a fortnightly clinic. 150 new patients have been evaluated with the majority also completing follow up visits to ensure recommendations are being implemented, to provide further support and to track progress. Patients and families are also invited to a peer support group which has proved beneficial.

Our service is now established and is delivering significant improvements in care for survivors of critical illness.

Successes include:

• Funding commitment from the CCG.
• Collated feedback from patients and families overwhelmingly positive indicating that the service is highly valued and effective in accelerating recovery.
• High volume of onward community therapy and medical referrals suggesting omissions in treatment/care are being identified and addressed (see suppl data).
• Positive impact on health related quality of life outcomes, return to work and health seeking behaviour.
• Collateral impact on within-ICU care by realignment of staff purpose towards long term patient-oriented goals and treating the patient as a person.
• Impetus for co-design of parallel ICU aftercare components including patient diaries and a peer support programme.
• Growing regional and international recognition within the field of ICU recovery
• NICE CG83 recommendations: 1.23, 1.24 and 1.25 inclusive, fully implemented.

In the long term we expect that, by proactively supporting patients after their stay in critical care, we will be able to demonstrate numerous clinical and financial benefits to our service:

Healthcare utilisation and efficiency

• reduce readmissions to emergency department and hospital
• reduce attendances at local GP practices
• reduce unplanned pharmacy consultation
• avoid missed follow-up appointments with specialist services o identify important new co-morbidities that need specialist review

Socio-economic

• assist in some patients returning to work earlier
• improve return to driving and independent living
• alleviate burden on carers (informal and formal)

Mental health 

• Highlight and treat unrecognised mental health issues including post-traumatic stress disorder, anxiety, depression, memory impairment and executive dysfunction

Personal

• Resilience, confidence and hope.

In addition to the clinic we have successfully established a face-to-face survivor peer support group, which has had four quarterly meetings attended by a total of 68 patients and relatives to date. Through our interactions with patients on the long road to recovery from critical illness, we are extremely privileged to hear and appreciate their positive and negative experiences of intensive care. Perhaps most valuably, we feed this back to the staff on our units and use the information to inform practice, realign purpose and enhance care.

Early phase

The crucial ingredients which allowed the pilot project to get off the ground were:

• The goodwill and motivation of two ICU consultants who brought experience from other centres in the follow-up of the critically ill.
• Time, experience and commitment of a critical care nurse and physiotherapist.
• A cumulative groundswell of interest in rehabilitation and recovery (with NICE CG83 at its heart) that had helped build awareness and broad local/MDT support.
• A strong ‘patient and family experience’ agenda at our Trust.
• Commitment to systematically gather demographic, clinical and outcome data for the purposes of monitoring performance and effectiveness.
• Use of patient feedback questionnaire.
• Engagement with Primary Care providers to understand how the service could assist them.
• Proactive engagement with existing post holders in therapy departments to secure informal contributions in the first instance, and only later formalising these arrangements.

Commissioning phase

We recognised that such a service would be impossible to sustain in the medium term without funding, facilities and the paid time of motivated colleagues. Based on the experience and metrics gathered to date, we prepared a business case outlining our vision. Crucial elements were stakeholder engagement (including community services, multi-professional colleagues and service managers) and positive feedback collated from patients and family who had attended clinic. Supportive comments from an invited GP were undoubtedly influential. We were fortunate to be able to demonstrate breadth of clinical support from across GSTFT Critical Care as well as interest from the South London Adult Critical Care Operational Delivery Network. Attention to relevant national guidance and documents (as well as NICE CG83) was important.

Foremost in driving forward our agenda were:

• Recommendations 1.23 to 1.25 of NICE CG83
• GPICS section 3.1.4
• NHS England requirement for post-ECMO follow up.