Implementation of a multidisciplinary rehabilitation prescription

NICE guidance post critical illness (CG83) states as early as clinically possible patients should be assessed to determine their physical and non-physical impairments. Patients short-term and medium-term goals should also be reviewed and updated throughout their rehabilitation pathway.

The team aimed to design and implement a rehabilitation pathway for patients using the NICE guideline and Quality Standard which specifically draws upon Quality Standard statements:

• 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.
• 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.

In 2015, staff on St George’s General Intensive Care Unit (GICU) attempted to implement a rehabilitation prescription (RP) which identified patient’s physical and non-physical impairments and the treatment and goals to overcome these. A lengthy guidance document was produced with poor compliance and practical application.

In June 2017, senior respiratory physiotherapists began work to re-explore the implementation of a RP on GICU. Whilst undertaking this work, NICE produced Quality Standard (QS158) defining the optimum rehabilitation pathway for the management of patients following critical illness. By utilising the RP we would be working towards compliance of Quality Statements 1 and 2, with aims to work towards quality statement 3 and 4 once established across the full pathway.

The first draft of the RP was produced in June 2017 by the physiotherapy team. Stakeholder review was undertaken in July, ensuring consultant, dietetics, speech and language therapy (SLT), physiotherapy and nursing by-in and the RP was modified. RP's were then implemented on the intensive care unit in August 2017.

The physiotherapy team on GICU have utilised multiple promotion methods within the implementation stage of the change process. Ensuring staff are aware of the RP document, understand its purpose and feel supported with using it. A mix of group teaching sessions to multi-disciplinary team (MDT) staff, utilising governance meetings to promote, highlighting the RP's through daily dissemination as part of the units 'Big 4' hot topics, MDT discussions at the long stay patient group (weekly), promotion through professional social media platforms such as 'Yammer', 1-1 bespoke teaching sessions and discussions with bedside nurses.

Analysis of the number of patients who qualified for RP to be initiated in August and September 2017 was performed using 4D Ward watcher software, thus allowing us to calculate the compliance with its completion. August showed a 41% compliance of the RP for those patients that qualified for its completion (n=54). Of these 41% had multi-professional input.

By September, compliance had risen to 51% and multi-professional input had risen to 80%. We expect both of these figures to continue to rise with the ongoing rolling training programme.

The key benefits of the project are that it has greatly enhances MDT working with a renewed focus on goal-orientated patient care. There has been improved documentation of rehabilitation goals and a stronger sense of a rehabilitation focus within critical care, as well as improved communication with the MDT regarding the rehabilitation needs of the critical care patients.

Creating and completing the RP was time consuming and in the next round of promotion, we will gather more feedback from the MDT in order to streamline the document which is hoped will further improve compliance.

An electronic copy will be created for staff to be able to update it without physically needing access to the medical notes and to prevent loss of the document on transfer of care between clinical areas.