Quality statement 2: Transfer from critical care to a general ward

Quality statement

Adults at risk of morbidity have a formal handover of care, including their agreed individualised structured rehabilitation programme, when they transfer from critical care to a general ward.

Rationale

Continuity of rehabilitation is very important because any breaks or gaps can set back or slow down recovery. A formal documented handover of care which includes the individualised, structured rehabilitation programme ensures that the general ward team understands the person's specific physical and non-physical rehabilitation needs, the goals they are working towards and how best to support them. This should ensure continuity of care and improve the person's experience of transfer from critical care to a general ward.

Quality measures

Structure

a) Evidence of formal handover processes between team discharging adults at risk of morbidity from critical care and team admitting them to a general ward.

Data source: Local data collection, for example, critical care discharge and ward admission protocols.

b) Evidence of local arrangements to ensure that the structured rehabilitation programme is included in the formal handover between the critical care team and the team admitting adults to a general ward.

Data source: Local data collection, for example, critical care discharge and ward admission protocols.

Process

a) Proportion of adults at risk of morbidity who have a formal handover of care when transferring from critical care to a general ward.

Numerator – the number in the denominator who have a formal handover of care.

Denominator – the number of adults at risk of morbidity transferring from critical care to a general ward.

Data source: Local data collection, for example, review of patient hospital records or observation in practice (to check for verbal handover).

b) Proportion of adults at risk of morbidity transferring from critical care to a general ward whose formal handover of care includes their individualised, structured rehabilitation programme.

Numerator – the number in the denominator whose handover of care includes their individualised, structured rehabilitation programme.

Denominator – the number of adults at risk of morbidity transferring from critical care to a general ward who have a formal handover of care.

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

Outcome

Level of satisfaction with continuity of care for adults who are discharged from critical care to a general ward.

Data source: Local data collection, for example, a patient survey.

What the quality statement means for different audiences

Service providers (hospitals) have procedures in place to ensure a formal handover of care takes place that includes the individualised, structured rehabilitation programme for adults at risk of morbidity transferring from critical care to a general ward. Handover should include members of multidisciplinary teams from critical care and the general ward.

Healthcare professionals (such as doctors, nurses, specialists in rehabilitation medicine, physiotherapists, psychologists, occupational therapists, speech and language therapists and dietitians) from critical care and the general ward work together in a formal handover of care, which includes the individualised, structured rehabilitation programme, when adults at risk of morbidity transfer from critical care to a general ward.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which members of multidisciplinary teams from critical care and the general ward work in an integrated way that ensures continuity of care and an uninterrupted support for adults at risk of morbidity when they transfer to a general ward.

Adults leaving critical care who are at risk of long-term problems have information about all of their needs (physical, psychological, emotional, sensory and communication) transferred to staff on the general ward by the team from critical care. This means the ward team understands what might help the person to recover (their rehabilitation needs). Adults should also have their condition explained to them, and to their family or carers if this is appropriate, and be encouraged to get involved in making decisions about their care.

Source guidance

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]

Formal handover of care

The handover of care on transfer from critical care to a general ward is the shared responsibility of the critical care team and the ward team.

The formal handover of care should be structured and should include:

  • a summary of the critical care stay, including diagnosis and treatment

  • a monitoring and investigation plan

  • a plan for ongoing treatment, including drugs and therapies, nutrition plan, infection status and any agreed limitations of treatment

  • an agreed individualised structured rehabilitation programme, including physical, psychological, emotional and cognitive needs

  • specific communication or language needs.

[Adapted from NICE's guideline on acutely ill adults in hospital, recommendation 1.15 and expert opinion]

Individualised, structured rehabilitation programme

The individualised, structured rehabilitation programme should address rehabilitation needs based on the comprehensive clinical assessment done in a critical care unit and identify the most recent goals agreed with the patient. The programme should be developed and delivered by members of a multidisciplinary team, and should include appropriate referrals, if applicable.

[Adapted from NICE's guideline on rehabilitation after critical illness in adults, recommendations 1.16 and 1.17]