Therapy Support Workers In Critical Care: Improving physical and cognitive rehabilitation

The aims of the project were to improve patient care and functional outcomes through increased frequency and intensity of physical and cognitive rehabilitation in in critical care.

Our objectives were to:

• Reduce length of stay in  patients specifically those who stay over 10 days by one day and by four days for those who stay over thirty days.
• Greater compliance with NICE guidelines and CQUIN requirements
• Improved patient experience/satisfaction
• Potential to reduce critical care and hospital readmission
• Reduce the number of services required by patients on discharge home.

Approximately 65 patients are admitted to critical care per month, and there is a particularly a high turnover of patients, 790 patients in 2012-2013 in 17 available beds. The average length of stay on critical care was 5.5 days in 2013. Local data analysis demonstrated that 100 patients have a length of stay over 10 days and 20 patients stay over 30 days critical care remains an area where discharge is complex and frequently delayed, particularly in patients with a prolonged stay.

Therapists play a crucial role within the multi-professional team (MPT) in facilitating discharge both in terms of maximising the patient’s physical function and psychological recovery as well as promoting independence and safety. We aimed to reduce the length of stay in patients who stay over 10 days.

The NICE guideline recommends that each patient has an assessment of their rehabilitation needs on admission to CC and states that patients must have a rehabilitation prescription on discharge from CC. This must be updated throughout the rest of the patient’s stay in hospital. Prior to the project the physiotherapy critical care team recognised that they were not consistently able to meet the NICE recommendations. Change was needed to improve our compliance with the NICE guidelines and provide a more comprehensive rehabilitation.

This was funded by the Trust's 'Dragons Den' project. The ‘Dragons’ included the Trusts chief executive, finance director, human resources director and two GP’s. The 'dragons' invested in the best ideas which focused on the Quality, Innovation, Productivity and Prevention (QIPP) initiatives for improved patient care within the Trust. The benefits identified were not only to reduce length of critical care stay but to release registered therapists time to assess and manage more complex patients, aid the transition from critical care to ward areas by providing follow up visits, ensuring the rehabilitation prescription is adhered to maintain the rehabilitation momentum that sometimes gets lost in an unfamiliar setting, to support and maintain rehabilitation on the ward to prevent readmission to CC from complications associated with immobility e.g. chest infection. We are now able to consistently meet the Core Standards in Intensive Care (2013) which stated that patients should receive at least 45 minutes of each indicated therapy 5 days a week.

The first stage was to address the lack of cognitive rehabilitation provided to patients in critical care and this required the employment of an occupational therapist (OT) specialising in critical care. When the next OT vacancy came up the advert had the criteria of experience in critical care. Therefore, a specialist OT was employed by to the Trust. This enabled the physiotherapy team to liaise closely with the OT to develop the role of a generic therapy support worker, to combine the provision of physical and cognitive rehabilitation skills. The next problem we faced was getting the right people for the jobs, as this was a new role they would have to be highly motivated, innovative and passionate individuals.

The interview was designed to assess these requirements. Neither of the TSW we employed had experience of working in critical care education and competency assessment was a high priority in order to get them working independently ASAP. Thirdly, our challenge was to integrate the TSW seamlessly in to critical care.

This was done through regular communication with staff, we displayed posters explaining their role and the TWS spent time with critical care nurses to understand their role and assist staff with turns, washing and functional activities to build relationships. No services were discontinued as a result of this project and the costs incurred were covered by the 'Dragon's Den' bid.

The improvements made were monitored by collecting data on length of stay in critical care and functional and cognitive rehabilitation outcomes. These are presented in quarterly reports (attached). In the first quarter (compared to the previous year) we were able to demonstrate a 14% increase in critical care admissions, planned admissions increased by 30%.

We demonstrated a 9% reduction in advanced respiratory days and a 8% reduction in level 3 bed days. 54 patients had been treated by the therapy support workers in the time frame (April-July 2015). Compared to the timeframe in the previous year there was a 1 day reduction in length of stay. This leads to an estimated cost saving of £59,400 in the first quarter alone! This is based on a modest cost point of £1,100 per patient per day stay in critical care for the 54 patients who were treated by the TSW (April-July 2015). Taking in to account the TWS employment costs this would translate to a £186,904 total saving over a year. In our second quarterly report we were able to demonstrate an increase in functional independence score for patients who have been in critcal care for over 10 days.

The data demonstrated movement in length of stay to the 0-10 days bracket with an increase in 84% of patients to 89%. It can be hypothesised that these patients have moved from the 11-29 days stay bracket which as reduced from 11% to 6.7%. We were also able to compare length of stay with the critical care unit at the Trust where this project has not been implemented; here we were able to show a reduction in the length of stay at this campus compared to a static length of stay in the campus where this project has not been implemented. We have had extremely positive feedback from consultants, patients and their relatives/carers (see attached reports).

The results exceeded our expectations and we also predict that length of hospital stay has been reduced and that patients are requiring less input from social services on discharge. We are currently collecting data on this to include in our annual report.

• Perform a prospective service evaluation to demonstrate a service need/development.
• Ensure you can demonstrate a service need & utilise appropriate evidence to support your application
• Use data analysts to assist you to utilise the data to demonstrate your service development, especially to show improved patient flow and financial savings
• Get people on board early and talk to business managers and experts about how to demonstrate the benefits of working in a new ways
• Prepare competencies and training before employment of staff, you need to be very clear about roles and boundaries
• Use lots of clear visuals, for example the commissioners were amazed to see critical care patients participating in early rehabilitation they thought they were all 'sedated and ventilated'
• Ask patients and their carers to share their experience of your service, they are great advocates. This project may not have worked if we hadn't employed the right people for the role.
• Try to involve medical staff as soon as possible and find an advocate for your service, we could have communicated better with our medical colleagues.
•  Identify who the main directorate is that would be using the service, for example digestive diseases and thoracics are the main user group, we could have involved the consultants and nurse specialists earlier in the project development.