Quality statement 4: Follow-up after critical care discharge

Quality statement

Adults who stayed in critical care for more than 4 days and were at risk of morbidity have a review 2 to 3 months after discharge from critical care.

Rationale

Follow-up is needed for adults who were in critical care for more than 4 days and at risk of morbidity, because further needs may become apparent after discharge. A review to reassess health and social care needs 2 to 3 months after discharge from critical care ensures that any new physical or non-physical problems are identified and further support is arranged as needed. Some adults who were in critical care for 4 days or less may also experience problems that need a review. Also, problems may emerge more than 3 months after discharge. The lifelong impact of a stay in critical care means that all adults who have experienced this should be able to self-refer and be reassessed at any time.

Quality measures

Structure

Evidence of local follow-up arrangements for adults who had a critical care stay of more than 4 days and were at risk of morbidity.

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

Process

Proportion of adults who were in critical care for more than 4 days and at risk of morbidity, who have a review between 2 and 3 months after discharge from critical care.

Numerator – the number in the denominator who have a review between 2 and 3 months after discharge from critical care.

Denominator – the number of adults who were in critical care for more than 4 days and at risk of morbidity, who have been discharged from critical care.

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

Outcome

a) Number of physical problems identified within 3 months of discharge from critical care.

Data source: Local data collection, for example, an audit of patient records.

b) Number of non-physical problems identified within 3 months of discharge from critical care.

Data source: Local data collection, for example, an audit of patient records.

c) Levels of satisfaction with support received to manage rehabilitation needs among adults discharged from critical care.

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

What the quality statement means for different audiences

Service providers (hospitals) have pathways in place to ensure that adults who stay in critical care for more than 4 days and are at risk of morbidity have a review 2 to 3 months after discharge from critical care to review their recovery and rehabilitation outcomes. They should also have arrangements in place to allow adults who have had a critical care stay to self-refer and be reassessed at any time.

Healthcare professionals (such as nurses, intensive care professionals, specialists in rehabilitation medicine, physiotherapists and clinical psychologists working in critical care follow-up clinics) carry out a review 2 to 3 months after discharge from critical care for adults who were in critical care for more than 4 days and at risk of morbidity. They do this by completing a rehabilitation assessment/questionnaire which includes functional reassessment of health and social care needs. The review can be either in the community or hospital. They also ensure that any adult who has had a critical care stay can be reassessed if they self-refer at any time.

Commissioners (clinical commissioning groups) ensure that they commission services that follow up adults who were in critical care for more than 4 days and at risk of morbidity with a review 2 to 3 months after discharge from critical care. They also ensure that services accept and reassess all adults who have had a critical care stay if they self-refer at any time after discharge.

Adults who were in critical care for more than 4 days and at risk of long-term problems have a review by a healthcare professional 2 to 3 months after leaving critical care to talk about their recovery and any problems they might have. These might include physical, cognitive, psychological, emotional, sensory or communication problems. At the meeting they should also talk about any social care or equipment needs so that extra support can be arranged if needed. All adults who have been in critical care should be able to attend a critical care follow-up clinic if they feel they need it.

Source guidance

Rehabilitation after critical illness in adults (2009) NICE guideline CG83, recommendations 1.1 and 1.23

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]

Review

A functional reassessment of the adult's health and social care needs, carried out face to face in the community or in hospital by a healthcare professional with training and skills in rehabilitation after critical care who is familiar with the adult's critical care problems, rehabilitation goals, individualised structured rehabilitation programme and rehabilitation care pathway. It should include the following physical and non-physical dimensions:

  • physical problems (physical dimension)

  • sensory problems (physical dimension)

  • communication problems (physical dimension and non-physical dimension)

  • social care or equipment needs (physical dimension)

  • anxiety (non-physical dimension)

  • depression and low mood (non-physical dimension)

  • post-traumatic stress-related symptoms (non-physical dimension)

  • behavioural and cognitive problems (non-physical dimension)

  • psychosocial problems (non-physical dimension).

[Adapted from NICE's guideline on rehabilitation after critical illness in adults, recommendations 1.20, 1.23 and 1.24]