Quality statement 1: Rehabilitation goals

Quality statement

Adults in critical care at risk of morbidity have their rehabilitation goals agreed within 4 days of admission to critical care or before discharge from critical care, whichever is sooner.

Rationale

Adults in critical care who are at risk of developing physical and non-physical morbidity need a comprehensive assessment to establish their rehabilitation needs and to put a rehabilitation plan in place. Rehabilitation goals need to be agreed with the person as early as possible to inform the rehabilitation programme. Starting rehabilitation early can improve physical and non-physical functioning and prevent future problems. The needs of a person in critical care can change very quickly, therefore goals should be continually reviewed and updated within the rehabilitation programme.

Quality measures

Structure

a) Evidence of local systems to flag when adults in critical care are at risk of morbidity.

Data source: Local data collection, for example, review of patient hospital records.

b) Evidence of local arrangements to ensure that adults in critical care at risk of morbidity have rehabilitation goals agreed and documented.

Data source: Local data collection, for example, review of patient hospital records.

Process

Proportion of adults in critical care at risk of morbidity who have their rehabilitation goals agreed within 4 days of being admitted to critical care or before discharge from critical care, whichever is sooner.

Numerator – the number in the denominator who have their rehabilitation goals agreed within 4 days of being admitted to critical care or before discharge from critical care, whichever is sooner.

Denominator – the number of adults in critical care who are at risk of morbidity.

Data source: Local data collection, for example, review of patient hospital records.

Outcome

Levels of satisfaction with involvement in their own care among adults in critical care.

Data source: Local data collection, for example, surveys of patients and their families.

What the quality statement means for different audiences

Service providers (hospitals) ensure that critical care pathways support identifying adults at risk of morbidity through a short clinical assessment and that all those identified as being at risk have a further comprehensive clinical assessment. Service providers put arrangements in place to ensure that adults' rehabilitation goals are based on the comprehensive clinical assessment and agreed within 4 days of being admitted to critical care or before discharge from critical care, whichever is sooner.

Healthcare professionals with experience in critical care and rehabilitation (such as intensive care professionals or other professionals with access to referral pathways) agree rehabilitation goals for adults in critical care who are at risk of morbidity, within 4 days of critical care admission or before critical care discharge, whichever is sooner. They ensure that goals are agreed with the patient if possible, reviewed and updated throughout rehabilitation. Family or carers may be involved if the person agrees; they will be involved if the person is unconscious or unable to give their agreement for treatment (formal consent).

Commissioners (clinical commissioning groups and NHS England) ensure that they commission critical care services which use a comprehensive clinical assessment to identify adults at risk of morbidity and establish their rehabilitation goals. They monitor the providers to ensure that this is done within 4 days of critical care admission or before discharge from critical care, whichever is sooner, reviewed and updated throughout rehabilitation.

Adults in critical care who are likely to benefit from more support have a thorough assessment to identify what might help them to recover (their rehabilitation needs). If they can, they talk with their healthcare team about how they hope they might recover and what they want to achieve (their rehabilitation goals), and then these goals are written in their notes. Family or carers may be involved if the person is happy with this; they will be involved if the person is unconscious or unable to give their agreement for treatment (formal consent). Goals should be agreed within 4 days of a person arriving in critical care, or earlier if they stay in critical care for less than 4 days.

Source guidance

Rehabilitation after critical illness in adults (2009) NICE guideline CG83, recommendation 1.4 and expert opinion

Definitions of terms used in this quality statement

Adults in critical care at risk of morbidity

People's risk of morbidity should be identified in a short clinical assessment that includes physical and non-physical elements. Examples include:

  • Physical

    • Anticipated long duration of critical care stay.

    • Obvious significant physical or neurological injury.

    • Unable to self-ventilate on 35% oxygen or less.

    • Presence of premorbid respiratory or mobility problems.

    • Risk or presence of malnutrition, changes in eating patterns, poor or excessive appetite, inability to eat or drink.

    • Unable to get in and out of bed independently.

    • Unable to mobilise independently over short distances.

  • Non-physical

    • Recurrent nightmares, particularly where patients report trying to stay awake to avoid nightmares.

    • Intrusive memories of traumatic events that have occurred before admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks).

    • Acute stress reactions, including symptoms of new and recurrent anxiety, panic attacks, fear, low mood, anger or irritability in the critical care unit.

    • Hallucinations, delusions and excessive worry or suspiciousness.

    • Expressing the wish not to talk about their illness or changing the subject quickly to another topic.

    • Lack of cognitive functioning to continue to exercise independently.

[Adapted from NICE's guideline on rehabilitation after critical illness in adults, recommendation 1.2, table 1 and expert opinion]

Rehabilitation goals

Rehabilitation goals can be short, medium or long term and will change throughout the patient's recovery from critical illness. They can be physical as well as psychological. Goals will need to be achievable and based on regular patient assessment of physical and non-physical consequences of the critical illness throughout their recovery.

For example, in the critical care unit, reduced mobility, weakness and fatigue will be the main problems, for which the overall goal will be early mobilisation. A short-term goal might be for the patient to be able to sit on the edge of the bed with support, a medium-term goal to stand aided and a long-term goal to march on the spot or take a few supported steps. Later, on the ward, reduced mobility will continue, but the goals will change; a short-term goal might be to walk to the toilet and a long-term goal to manage the stairs before discharge.

[Expert opinion]