Critical Care

Rehabilitation Pathway (Standards)

Document control: This document replaces the South East Coast Critical Care Network Critical Care Rehabilitation Pathway User Guide Caroline Wilson 11/03/16 Presented to Network Leads

CW & MC 08/07/16 Agreed at Network Leads Meeting CW & MC Revision following NICE QS158

SECCN C&G Forum 05/09/2018 Revision agreed

Contents

Flowchart Standards for Critical Care Rehabilitation Pathway Documents Assessment Tools

Hospital Anxiety Depression Scale

Post Traumatic Stress Disorder Assessment Tool

Barthel Activities of Daily Living Index

RASS Score & CAM-ICU Score

CPAx Assessment tool

Throughout this document the term at risk will be used in lieu of the longer terminology at risk of long term morbidity as a consequence of critical illness. Morbidity may be multi-factorial including physical, psychological and cognitive sequelae. The term Rehabilitation is used to denote all stages of the pathway including follow up. These pathway standards underpin an integrated approach to meeting all patients’ needs through multidisciplinary input.

Critical Care Rehabilitation Pathway Flowchart

SCA: Short Clinical Assessment CCA: Comprehensive Clinical Assessment

Patient Admitted to Critical Care

Perform SCA

as early as clinically possible

within 4 days of admission and/or prior to discharge to the ward

Multi Trauma patient

Stroke patient

Cardiac patient

Enhanced Recovery patient

Is patient at risk?

No Yes

Perform CCA Agree and document rehabilitation goals within 4 days of admission to Critical Care

and/or prior to discharge to the ward

If patient

deteriorates

Repeat SCA prior to discharge to the ward if

appropriate

Refer to appropriate rehabilitation

prescription/pathway

Repeat CCA on the ward prior to discharge home

Review & Update rehabilitation goals

Review in follow up clinic/rehabilitation class 2-3 months post discharge

Identify any further actions

No

Repeat SCA if concerns highlighted by ward

staff

No Yes

Patient discharged into the community/home

Patient discharged to the ward

Commence Rehabilitation

Documentation

Yes

Is patient at risk?

Is patient at risk?

Standards for Critical Care Rehabilitation Pathway Documentation Trusts within South East Critical Care Network use locally designed rehabilitation pathways. This document outlines the key components of a pathway document.

Essential components of the Rehabilitation Pathway 1. Short Clinical Assessment (other terminology may be used) Complete the following assessments:

1. On Admission to Critical Care – complete a Short Clinical assessment as early as clinically possible to determine the patient’s risk of developing morbidity as a consequence of their critical illness and stay in Critical Care

2. Discharge from Critical Care to the Ward – for patients yet to receive a Short Clinical Assessment and those previously deemed at low risk the Short Clinical Assessment should be performed before discharge from critical care to ascertain their current risk level

3. On the Ward –for patients previously deemed at low risk the Short Clinical Assessment should be repeated if concerns are raised by ward staff to determine their current risk level

The Short Clinical Assessment should go with the patient to the ward and be included in the handover process. 2. Comprehensive Clinical Assessment (other terminology may be used) A Comprehensive Clinical Assessment should be completed within 4 days of admission to Critical Care (at a time appropriate to the patient’s condition but prior to discharge to the ward) or whilst on the ward for all patients identified at risk and short and medium rehabilitation goals agreed and documented.

The assessment can be structured using assessment tools for functional; nutritional, cognitive and psychological assessment and patient experience

A functional assessment should be performed by the physiotherapist in order to focus the physiotherapy goals to facilitate the patient’s rehabilitation and to align rehabilitation with weaning from ventilatory support if applicable

Identify specific rehabilitation goals not already specified in the nursing, physiotherapy or medical care plan

Short and medium term rehabilitation goals should be agreed, whenever possible, with the patient, and ideally involving the patient's family and/or carer

The goals are to be documented within the pathway along with progress notes and any referrals that have been made to facilitate the patient's full recovery

Repeat a Comprehensive Clinical Assessment whenever clinically indicated

Stages of the Rehabilitation Pathway (for all patients deemed at risk) Whilst in Critical Care Rehabilitation should include measures to prevent avoidable morbidity and to facilitate recovery from identified morbidity related to the patient's episode of critical illness. This should include recognition and management of delirium and early mobilisation where clinically indicated. Referral Considerations: Dietician Pharmacist Speech and Language Therapist Occupational Therapist Patient diaries should be completed for patients in line with Trust guidelines and all patients should receive both written and spoken information about their critical care stay. Before discharge from Critical Care A Comprehensive Clinical Assessment and functional assessment should be performed/repeated and the patient’s short and medium term rehabilitation goals should be (re)assessed with the patient, ideally involving the patient’s family and/or carer. The goals are to be documented within the pathway along with progress notes and any referrals that have been made to facilitate the patient's full recovery. An individualised rehabilitation manual plan should be available and given to the patient, at the point in their pathway appropriate to their rehabilitation needs, offering them a structured and supported rehabilitation programme for at least 6 weeks following their discharge from critical care. The manual may contain general advice, techniques to overcome cognitive dysfunctions and a programme of exercise. It may be appropriate to return and discuss the patient diary at this point; however, not all patients will be “ready” for this. Some patients may wish to continue their diary whilst on the ward. Information must be given to the patient and their family and/or carer about transition from critical care to the ward environment. Referral Considerations: Dietician Pharmacist Speech and Language Therapist Occupation Therapist Rehabilitation Lead

Ensure that a formal structured handover of patient care is in line with NICE QS158 and NICE CG50 “Acutely ill patients in hospital”. This should include the formal handover of the individualised, structured rehabilitation programme. During ward based care A Comprehensive Clinical Assessment and functional assessment should be performed/repeated and the patient’s current rehabilitation needs and goals identified with the patient, ideally involving the patient's family and/or carer. The goals are to be documented within the pathway along with progress notes and any referrals that have been made to facilitate the patient’s full recovery. The patients’ rehabilitation goals should be documented to inform all staff involved with their care. Review the possibility of retuning and discussing the patient diary. Give the patient their rehabilitation manual if appropriate. Give the patient written and spoken information about their critical care stay. Referral Considerations: Dietician Pharmacist Speech and Language – swallow assessment Community Occupation Therapist Clinical psychology Before Discharge to home A Comprehensive Clinical Assessment and functional assessment should be performed/repeated and based on this assessment the patients rehabilitation goals in their individualised manual should be reviewed updated and new goals agreed with the patient. Review the possibility of returning and discussing the patient diary. Give the patient their rehabilitation manual if appropriate. Give the patient a copy of their critical care discharge summary. Give the patient written and spoken information about discharge arrangements and any referrals for ongoing care and general guidance on what to expect at home (including returning to work, driving and local support services). Ensure all discharge documents are completed and forwarded to the appropriate discharge services. Check the information booklet(s) have been given to the patient or family. Give the patient and family the opportunity to provide feedback about their experience of Critical Care and Critical Care rehabilitation. Referral Considerations: Social Worker – social assessment Community Physiotherapist Community Occupational Therapist District Nurse

Dietician Clinical Psychology Follow up 2/3 months after discharge from hospital The location of the follow up assessment will be influenced by the Trusts' provision for rehabilitation. The assessment should ideally be face to face in the hospital or community setting, performed by appropriately skilled healthcare professionals who are familiar with the patients critical care problems and rehabilitation pathway. At follow up the patient should be assessed, combining the Comprehensive Clinical Assessment and other functional assessment tools as per Trust policy, to determine on-going health, psychological and social care needs. The follow up session may combine a physical rehabilitation group but the rehabilitation group should not be the sole means of follow up; provision must be made to ensure for individual patient assessment and discussion and the follow up of patients who do not attend the group. The patient and family should be given the opportunity to provide feedback about their experience of Critical Care and Critical Care rehabilitation.

Tools to help with Assessment These tools are to assist with the assessment of the patients; they are not diagnostic tools but merely give an indication of potential problems. They then can provide a baseline on which to formulate the rehabilitation goals.

HADS The higher the score in the assessment the greater the indication the patient may be suffering with some form of depression and/or anxiety.

PTSD The higher the score in the assessment the greater the indication the patient may be suffering with some form of Post-Traumatic Stress Disorder

Barthel Activities of Daily Living Index This tool helps you assess patients’ ability to perform the activities of daily living. The higher the score the more independent the patient and low scores highlights areas that can be improved.

RASS SCORE & CAM – ICU SCORE This tool is to assist in the monitoring of delirium for ICU patients. The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are well validated delirium assessment tools. For further information please refer to www.icudelirium.org

CPAx Physiotherapy Assessment Tool The Chelsea Critical Care assessment tool. A tool to measure physical morbidity in the general adult critical care patient.

HAD Scale I feel tense or “wound up” A I feel as if I’m slowed down D

Most of the time 3 Nearly all the time 3 A lot of the time 2 Very often 2

Time to time / occasionally 1 Sometimes 1 Not at all 0 Not at all 0

I get a sort of frightened felling as if something awful is about to happen

A I get a sort of frightened feeling like

“butterflies” in the stomach A

Very definitely and quite badly 3 Not at all 0 Yes, but no too badly 2 Occasionally 1

A little but it does not worry me 1 Quite often 2 Not at all 0 Very often 3

I still enjoy the things I used to enjoy D I have lost interest in my appearance D

Definitely as much 0 Definitely 3 Not quite as much 1 I don’t take as much care as I should 2

Only a little 2 I may not take quite as much care 1 Hardly at all 3 I just take as much care as ever 0

I can laugh and see the funny side of things D I feel restless as if I have to be on the move. A

Not as much as I always could 0 Very much indeed 3 Not quite as much now 1 Quite a lot 2

Definitely not as much now 2 Not very much 1 Not at all 3 Not at all 0

Worrying thoughts go through my mind A I look forward with enjoyment to things D A great deal of the time 3 As much as I ever did 0

A lot of the time 2 Rather less than I used to 1 From time to time but not often 1 Definitely less than I used to 2

Only occasionally 0 Hardly at all 3 I feel cheerful D I get sudden feelings of panic A

Not all the time 3 Very often indeed 3 Most often 2 Quite often 2 Sometimes 1 Not very often 1

Most of the time 0 Not at all 0 I can sit and ease and feel relaxed

A I enjoy a good book or radio / TV programme

D

Definitely 0 Often 0 Usually 1 Sometimes 1

Not often 2 Not often 2 Not at all 3 Very seldom 3

0-7 Normal

8-10 Cause for concern, monitor for change

11-21 Probable clinical case requires assessment

Affix Patient Label NHS number: ……………………………………….. Hospital Number: ………………………………… Surname: …………………………………………….. Forename: ………………………………………….. D.O.B. …………………………………………… Address: ……………………………………………. ………………………………………………………………

Trust Logo

Post-Traumatic Stress Disorder Assessment Tool

A. When I think back to the time of my severe illness and the time I spent in the ICU, I remember:

NO YES

Nightmares

Severe anxiety or Panic

Severe Pain

Trouble to breathe, feelings of suffocation

B. Presently (this means in the past few days) I suffer from:

Never Sleep Problems Always

1 2 3 4 5 6 7

Nightmares

1 2 3 4 5 6 7

Depression, I feel dejected / downtrodden

1 2 3 4 5 6 7

Jumpiness, I am easily frightened by sudden sounds or sudden movements

1 2 3 4 5 6 7

The need to withdraw from others

1 2 3 4 5 6 7

Irritability, that is, I am easily agitated / annoyed and angry

1 2 3 4 5 6 7

Frequent mood swings

1 2 3 4 5 6 7

A bad conscience, blame myself, have guilt feelings

1 2 3 4 5 6 7

Fear of places and situations, which remind me of ITU

1 2 3 4 5 6 7

Muscular tension

1 2 3 4 5 6 7

Upsetting, unwanted thoughts of images of my time in ITU

1 2 3 4 5 6 7

Feeling numb (e.g. cannot cry, unable to have loving feelings)

1 2 3 4 5 6 7

Avoid places, people or situations that remind me of ITU

1 2 3 4 5 6 7

Feeling as if my plans or dreams for the future will not come true

1 2 3 4 5 6 7

Affix Patient Label NHS number: ……………………………………….. Hospital Number: ………………………………… Surname: …………………………………………….. Forename: ………………………………………….. D.O.B. …………………………………………… Address: ……………………………………………. ………………………………………………………………

Trust Logo

Date

Bowels Incontinent Occasional Accident (1 per week)

Continent

0

1

2

Bladder Incontinent or catheterised & unable to manage Occasional Accident (max 1 x24 hours)

Continent over 7 days

0

1

2

Grooming Needs help Independent, face ,hair, teeth, shaving

0

1

Toilet Use Dependent Needs some help but can do something

Independent (on and off, dressing, wiping

0

1

2

Feeding Unable Needs help cutting, spreading butter etc.

Independent

0

1

2

Transfer Unable Major help (1-2 people, physical)

Minor help (verbal or physical) Independent

0

1

2

3

Mobility Immobile Wheelchair independent inc. corners etc.

Walks with help of 1 person (verbal or physical) Independent (but may use any aid, e.g. Stick)

0

1

2

3

Dressing Dependent Needs help but can do half unaided

Independent

0

1

2

Stairs Unable Needs help (verbal, physical, carrying aid)

Independent up and down

0

1

2

Bathing Dependent Independent

0

1

TOTAL

Affix Patient Label NHS number: ……………………………………….. Hospital Number: ………………………………… Surname: …………………………………………….. Forename: ………………………………………….. D.O.B. …………………………………………… Address: …………………………………………….

Trust Logo

Barthel Activities of Daily Living Index

CPAx Physiotherapy Assessment Tool

Aspect of Physicality

Level 0 Level 1 Level 2 Level 3 Level 4 Level 5

Respiratory Function

Complete ventilator dependence. Mandatory breaths only. May be fully sedated/ paralysed.

Ventilator dependence. Mandatory breaths with some spontaneous effort.

Spontaneously breathing with continuous invasive or non-invasive ventilatory support.

Spontaneously breathing with intermittent invasive or non-invasive ventilatory support Or continuous high flow oxygen (>15litres).

Receiving standard oxygen therapy (<15 litres).

Self-ventilating with no oxygen therapy.

Cough Absent cough, may be fully sedated or paralysed.

Cough stimulated on deep suctioning only.

Weak ineffective voluntary cough, unable to clear independently e.g. requires deep suction.

Weak, partially effective voluntary cough, sometimes able to clear secretions e.g. requires yanker suctioning.

Effective cough, clearing secretions with airways clearance techniques.

Consistent effective voluntary cough, clearing secretions independently.

Moving Within the Bed e.g. rolling.

Unable, maybe fully sedated/ paralysed.

Initiates movement. Requires assistance ≥ 2 people (maximal).

Initiates movement. Requires assistance≥1 person (moderate).

Initiates movement. Requires assistance 1 person (minimal).

Independent in ≥3 seconds.

Independent in <3 seconds.

Supine to Sitting on the Edge of the Bed.

Unable/ Unstable. Initiates movement. Requires assistance ≥ 2 people (maximal).

Initiates movement. Requires assistance≥1 person (moderate).

Initiates movement. Requires assistance 1 person (minimal).

Independent in ≥3 seconds.

Independent in <3 seconds.

Dynamic Sitting (i.e. when sitting on the edge of the bed/unsupported sitting)

Unable/ Unstable Requires assistance ≥2 people (maximal).

Requires assistance≥1 person (moderate).

Requires assistance 1 person (minimal).

Independent with some dynamic sitting balance, i.e. able to alter trunk position within base of support.

Independent with full dynamic sitting balance, i.e. able to reach out of base of support.

Standing Balance

Unable/ unstable/ bedbound.

Tilt table or similar Standing hoist or similar.

Dependant on frame, crutches or similar.

Independent without aides.

Independent without aids and full dynamic standing balance, i.e. able to reach out of base of support.

Sit to Stand (Starting position: ≤ 90 degrees hip flexion)

Unable/ Unstable. Sit to stand with maximal assistance e.g. standing hoist or similar.

Sit to stand with moderate assistance e.g. 1-2 people.

Sit to stand with minimal assistance e.g. 1 person.

Sit to stand independently pushing through arms of the chair.

Sit to stand independently without upper limb involvement.

Transferring from Bed to Chair.

Unable/ Unstable.

Full hoist. Standing hoist or similar.

Pivot transfer (no stepping) with mobility aid or physical assistance.

Stand and step transfer with mobility aid OR physical assistance.

Independent transfer without equipment.

Stepping Unable/ Unstable.

Using a standing hoist, or similar.

Using mobility aids AND assistance > 1 person (moderate).

Using mobility aid AND assistance 1 person (minimal).

Using mobility aid OR assistance 1 (minimal).

Independent without aid.

Grip Strength (predicted mean for age and gender on the strongest hand.)

Unable to assess. < 20% < 40% < 60% < 80% ≥80%

Date Respiratory function

Cough Moving within the bed

Supine to sitting on the edge of the bed

Dynamic sitting

Standing balance

Sit to stand

Transferring bed to chair

Stepping Grip Strength

Total Signed Comments

CPAx Score over time

Number: Date:

50

48

46

44

42

40

38

36

34

32

30

28

26

24

22

20

18

16

14

12

10

8

6

4

2

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

DATE

SCORE