Supporting community recovery and reducing readmission risk following critical illness in icu survivors

Abstract

Introduction: Survivors of critical illness experience multidimensional disabilities that include physical, psychological and cognitive decline, social challenges and reduced quality of life. This accumulation has been termed post-intensive care syndrome (PICS) (1), with 25–30% requiring unplanned hospital readmission within 3 months following index hospitalisation(2). Impact is also high for families/carers, especially in social & psychological domains. Post-ICU recovery programs have not been widely studied or adopted despite the scope of these problems. Methods: Listening to and Learning from ICU Survivors and Families/Carers To understand the complexity of ICU survivorship, and reasons for early unplanned hospital readmission, we conducted a mixed methods study involving patients and families/carers (3,4). This involved in-depth 1-2-1 interviews and focus groups with ICU survivors (n=50) and families/carers (n=51). This with a view to informing the evidence-based development of clinically and cost-effective interventions for a new integrated care pathway in Scotland’s second largest Health Board NHS Lothian. For around half our patients a ’complex health & psychosocial needs’ context occurred with multi-morbidity and polypharmacy, significant psychological & mobility issues, problems with specialist aids/equipment and fragile social support prior to critical illness. ICU survivors described inadequate preparation for hospital discharge, poor communication between secondary/primary care, and inadequate support with psychological care, medications and goal setting. Aim, Practice Change Implemented & Timeline: We aimed to introduce a new integrated care pathway providing holistic, multi-disciplinary hospital assessment and improved community support for ICU survivors. Consequently, we secured funding for a 15 month Quality Improvement project starting 1st March 2018. We developed (i) an ICU holistic needs assessment tool to facilitate early identification of ICU survivors at risk of unplanned readmission; (ii) introduced in-hospital holistic needs assessment to identify clinical and psychosocial needs of ‘at risk’ ICU survivors; (iii) developed more formal and quicker communication links between ICU hospital assessment staff and GP’s, community multi-disciplinary NHS locality HUBS, community pharmacies and third sector community social prescribing groups; (iv) facilitated community follow up of ICU survivors at 2 and 8 weeks after hospital discharge. Highlights, Sustainability/Transferability: We present case studies and evaluation data from our new anticipatory care pathway intervention highlighting improved holistic in-hospital assessment of ICU survivors. We highlight processes undertaken that facilitated quicker and better communication between hospital ICU staff and GPs, NHS locality HUBS, community pharmacies and third sector community groups. We demonstrate benefits to ICU survivors and families/carers of the new integrated care pathway improving community recovery and reducing unplanned hospital readmission risk which is sustainable and transferable. References: 1- Needham DM, et al. Improving long-term outcomes after discharge from intensive care unit. Crit Care Med 2012; 40:502–9 2- Lone NI, et al. Five-year mortality and hospital costs associated with surviving intensive care. Am J Respir Crit Care Med2016; 194:198–208. 3- Lone NI, et al. Predicting risk of unplanned hospital readmission in survivors of critical illness. Thorax Apr 2018, thoraxjnl-2017-210822; DOI: 10.1136/ 4- Donaghy E, et al. Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients and carers BMJ Quality & Safety May 2018, bmjqs-2017-007513; DOI: 10.1136

Keywords

• critical illness
• icu survivor
• new care pathways
• integrated care
• community recovery