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The Intensive Care Society 2011

Audit and survey

Rehabilitation within Scottish intensive care units: a national survey


RTD Appleton, M MacKinnon, MG Booth, J Wells, T Quasim
The National Institute for Health and Clinical Excellence (NICE) in Clinical Guideline 83: Rehabilitation after critical illness has set challenging recommendations regarding the routine evaluation for, and provision of, rehabilitation within critical care units. There is no published information regarding current practice in the UK. To establish current practice in Scotland we undertook a telephone survey of all 23 Scottish ICU lead clinicians and physiotherapists 96% of lead clinicians and 100% of lead physiotherapists completed the survey. Routine assessment for physical (median two (IQR 1-3 [range 0-4])) and non-physical sequelae (median zero (IQR 0-2 [range 0-5])) is low. Aproximately half of ICUs (52%) provide an individualised, structured rehabilitation programme, 32% include activities of daily living and all provide low intensity rehabilitation (eg limb stretching and positioning exercises). There are significant differences (all p<0.05) in the number of units routinely providing more intensive rehabilitation (eg mobilising) while patients have an endotracheal tube versus once extubated.
Keywords: survey; intensive care; critical care; rehabilitation; risk assessment

Introduction
Survival from critical illness over the last decade in the UK has increased.1,2 The national audit reports from the Scottish Intensive Care Society and the Intensive Care National Audit and Research Centre Case Mix Programme have both demonstrated hospital survival rates in excess of 70%.1,2 With the improved survival following an episode of critical illness, focus has now shifted towards quality of life issues. Studies have found multiple commonly occurring problems; physical ailments, such as weakness,3 fatigue4 and impaired physical functioning,5 as well as psychological issues such as depression,6 anxiety,7 post-traumatic stress disorder (PTSD)8 and a decline in cognitive function.9 The National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 83: Rehabilitation after critical illness10 was published in 2009 aiming to improve the identification, prevention and treatment of these sequelae. While the guideline acknowledges the limited evidence base, it makes several recommendations that are challenging to implement. These include: The routine assessment of all ICU patients to determine both their risk of developing physical and non-physical sequelae and their rehabilitation requirements. The implementation of an individualised, structured rehabilitation programme including the setting and review of rehabilitation goals in all those deemed at risk of sequelae. The involvement of the patients family in setting rehabilitation goals. The provision of information to patients (if appropriate) and their families/carers regarding the patients illness,
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treatments, possible short-term and long-term physical and non-physical sequelae, the rehabilitation care pathway and the differences between critical care and ward-based care. There is no published information regarding either the requirement for, or provision of, rehabilitation within UK ICUs. The aims of our survey were therefore to establish: The awareness of the NICE clinical guideline among Scotlands intensive care lead clinicians and physiotherapists. The current practice of risk assessment of ICU patients for the development of physical and non-physical sequelae. The current provision of information to patients, their families/carers and general practitioners regarding the patients illness, treatments and potential sequelae. The perceived barriers to the provision of rehabilitation within Scottish ICUs. The opinion of the Scottish ICU lead clinicians regarding the benefit of greater provision of rehabilitation within the ICU and the value of the NICE clinical guideline. The percentage of Scottish ICUs receiving funding specifically for the provision of rehabilitation within the ICU. The rehabilitation therapies currently provided within Scottish ICUs. The setting of rehabilitation goals for patients in the ICU and the involvement of patients families.

Methods
A two-part telephone survey was devised; part A for clinicians and part B for physiotherapists. The questions were predetermined (Appendix A) with a fixed range of optional
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Endotracheal tube in-situ Yes Sitting over bedside Sitting up in chair Standing up Mobilising on feet 15 14 13 11 No 8 9 10 12

Extubated or tracheostomy tube in situ Yes 22 21 22 20 No 1 2 1 3

p value

0.022 0.035 0.004 0.011

Table 1 Comparison of the number of Scottish ICUs routinely providing more intensive rehabilitation therapies while the patients have an endotracheal tube in-situ versus once the patient is either extubated or has a tracheostomy tube in-situ.

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Percentage of Scottish ICUs

Percentage of Scottish ICUs


Physical problems Sensory problems Communication problems Social care/ equipment needs

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Physical sequelae

Figure 1 The percentage of Scottish ICUs formally assessing for physical sequelae on ICU discharge ( ), at another time point during the ICU stay ( ) or not assessed ( ). Key: Physical problems such as weakness, fatigue and swallowing difficulties. Sensory problems such as changes in vision or hearing. Communication problems such as difficulty in speaking or writing. Social care/equipment needs such as mobility aids, benefits or employment.

Non-physical sequelae

answers provided for the majority of questions. Additional space was provided to allow free text comments. Between May and July 2010 each lead clinician and physiotherapist for the 23 general adult ICUs in Scotland was contacted by telephone by one of two authors (RA and MMcK). A survey data collection sheet was completed during each telephone interview and the data collated and analysed with Microsoft Excel. Statistical analysis of the data was performed using SPSS version 15.0 (SPSS Inc, Chicago, IL, USA). Fishers Exact test was used to compare nominal data.

Figure 2 The percentage of Scottish ICUs formally assessing for nonphysical sequelae on ICU discharge ( ), at another time point during the ICU stay ( ) or not assessed ( ). Key: Psychosocial problems such as relationship difficulties with the family and/or carer(s); Behavioural/cognitive problems such as with confusion, impaired attention or memory; *PTSD; posttraumatic stress disorder.

Results
All 23 Scottish ICUs were contacted; 96% of the lead clinicians and 100% of the lead physiotherapists completed the survey. Half of the lead clinicians and 83% of the lead physiotherapists were aware of the NICE guideline, although only a minority had actually read them (14% of the lead clinicians and 30% of the lead physiotherapists). Of those who had read the guideline, 66% felt that it was a useful publication.

Lead clinicians
The percentage of Scottish ICUs formally assessing for physical and non-physical sequelae are given in Figures 1 and 2. The median number of physical dimensions formally assessed per
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ICU was two (IQR 1-3 [range 0-4]) while for the non-physical dimensions the median number was zero (IQR 0-2 [range 05]). The assessments are undertaken as part of routine patient care and in general specific assessment tools are not routinely used. Formal speech and language assessment referrals are made in 23% of ICUs and social work referrals in 5%. The Confusion Assessment Method for ICU (CAM-ICU) is routinely used in 14% of ICUs and referral to liaison psychiatry occurs in 5% of ICUs. Regarding an episode of critical illness and its treatments, verbal information is routinely provided to patients in 59% of Scottish ICUs, to the patients family in 86% and to the patients general practitioner in 5% of ICUs. No Scottish ICU surveyed routinely provides written information to the patient and 14% routinely provide written information to the patients family. While 68% of ICUs routinely provide written information to the patients GP , it is usually in the form of a discharge letter. With regard to outcomes and sequelae following critical illness, 27% of Scottish ICUs routinely provide information (either written or verbal) to the patient, 50% routinely provide this information to the patients family and 41% provide this information to the patients GP .
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B pr eha ob vo lem ura s l/co gn iti ve

De pr es sio n

Ps yc ho so cia lp ro ble m s

An xie ty

PT SD *

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Physiotherapists
All Scottish ICUs routinely provide respiratory physiotherapy, limb stretching and limb positioning. The majority of ICUs routinely provide limb strengthening exercises (96%) and limb splinting (78%), while single units use cycle ergometry and the Nintendo Wii Sports for rehabilitation. Table 1 compares the number of Scottish ICUs routinely providing the more intensive physical rehabilitation therapies while the patients have an endotracheal tube in place compared with those who have been extubated or have a tracheostomy. Just over half (52%) of ICUs provide an individualised, structured rehabilitation programme and 30% incorporate activities of daily living (ADLs) into this. Most ICUs routinely set short-term rehabilitation goals (78%) and 26% routinely set medium-term goals. The patients family or carers are involved in the discussions in a third of ICUs that routinely set rehabilitation goals. In 96% of units, the ICU physiotherapists routinely give a formal handover of the rehabilitation needs of the patients to their ward counterparts.

Factors perceived to limit the provision of rehabilitation

Figure 3 The factors perceived to limit the provision of rehabilitation within Scottish ICUs and the percentage of ICUs in which these factors were felt to be present and limiting the provision of rehabilitation; yes ( ), no ( ), dont know ( ).

Summary of results
The surveys main findings are: The majority of the Scottish ICU lead clinicians and lead physiotherapists were aware of the NICE guideline though only a minority had read it. Many of the NICE guidelines recommendations are not being routinely implemented in Scottish ICUs. The routine assessment of ICU patients for some physical sequelae occurred in the majority of Scottish ICUs though the routine assessment for non-physical sequelae occurred in only a minority. Formal assessment tools for both physical and non-physical sequelae were not largely used. The majority of Scottish ICUs routinely provide verbal information to patients and their families regarding the patients critical illness and treatments, though few provide written information. Only a minority of Scottish ICUs provide information regarding potential physical and non-physical sequelae to the patient, their families and the GP . There were multiple factors felt to be present within Scottish ICUs limiting the provision of rehabilitation patient severity of illness, sedation, insufficient equipment and insufficient funding were felt to be present in the majority
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of Scottish ICUs. The majority of Scottish ICU lead clinicians felt patients would benefit from greater rehabilitation within the ICU. The majority of Scottish ICUs do not receive funding specifically for the rehabilitation of patients within the ICU. Almost all Scottish ICUs routinely provide the low intensity physical therapies (eg limb stretching) though there was a significant difference in the number of Scottish ICUs providing the higher intensity physical therapies (eg sitting over the bedside) when a endotracheal tube is in-situ versus following extubation or when a tracheostomy is in-situ. The majority of Scottish ICUs do not include ADLs into rehabilitation therapy. The majority of Scottish ICUs routinely set rehabilitation goals to be achieved by the end of the hospital admission, though only a minority set goals for beyond the hospital admission to facilitate the patients subsequent return to normal daily activities.

Discussion
The implementation of clinical guidelines is variable and frequently low.11,12 A systematic review by Cabana et al13 synthesised seven categories of barriers to guideline implementation; a lack of awareness, familiarity or agreement with the guideline; a lack of motivation; lack of clinician selfefficacy; lack of clinician belief in outcome expectancy and external barriers (eg lack of resource). While we did not explore the reasoning for any lack of guideline implementation, some explanations are possible. Only 50% of lead clinicians were aware of the guideline and only 27% of lead clinicians and 37% of physiotherapists who were aware of the guideline had read them. This suggests a lack of familiarity and/or a negative clinician attitude towards the guideline. There are currently no Scottish guidelines for critical care.14 The combination of a lack of feasibility for separate Scottish guidelines and the previous endorsement of NICE guidelines by the Scottish Intensive Care Society15 supports their adoption in Scottish critical care.
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Pa tie nt

Prior to ICU discharge, the majority of ICUs (77%) provide information to both patients and their families regarding the differences between critical care and ward-based care and the transfer of clinical responsibility to a different medical team. The majority (91%) of Scottish ICUs do not receive funding specifically for rehabilitation. Any rehabilitation provided is usually from the generic hospital pool of physiotherapy staff rather than by dedicated ICU physiotherapists. Among lead clinicians, 64% feel their patients would benefit from more rehabilitation. The perceived limitations to the provision of rehabilitation and the percentage of Scottish ICUs in which these factors were felt to be present and limiting the provision of rehabilitation are presented in Figure 3.

90% 80%

Percentage of Scottish ICUs

70% 60% 50% 40% 30% 20% 10% 0%

of illn es In s su ffi cie nt fu nd ing

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The routine assessment and use of formal assessment tools for physical and non-physical sequelae in ICU in Scotland were generally low. The NICE guideline highlights the limited evidence base available for most assessment tools and for many sequelae (fatigue, mobility, swallowing dysfunction, communication problems, sensory disturbance, post-traumatic stress disorder, depression) there are no tools that have been validated within the critical care setting. It is therefore understandable why so few are used. Recent publications16,17 recommend the routine use of the diagnostic criteria for ICUacquired weakness16 and the confusion assessment method for ICU (CAM-ICU).17 There is good evidence from the critical care setting regarding the validity of these tools18-22 and interrater reliability18,19,22,23 supporting their adoption into routine clinical practice. For the large range of other potential sequelae, clinical judgment with early specialist referral, for example to psychiatry or speech and language therapy, through locally agreed referral pathways would appear to be a pragmatic choice. The majority of ICUs communicated verbally with patients and their relatives. Work by Sawdon et al24 demonstrated that many patients have little or no recollection of events during their ICU stay and work by Fan et al25 showed that over 50% of ICU patients surviving acute lung injury are either delirious or comatose both following extubation and at the point of ICU discharge. This suggests that verbal information alone will be largely ineffectual and should perhaps be supplemented with written information. There is evidence to support the use of patient diaries in reducing anxiety and depression.26 These are compiled by the ICU nursing staff and relatives. Few Scottish ICUs routinely provide information regarding the potential sequelae of critical illness to patients and their families yet studies27,28 have found that patients and their relatives seek this information as well as information regarding the recovery process. Evidence supporting self-help manuals is currently conflicting29,30 though they may be of benefit in the short term.29 A nurse-led intensive care follow-up programme was not found to be effective in improving patient quality of life.30 A simple, effective method of providing tailored information to patients and their relatives regarding an episode of critical illness, potential sequelae and the recovery period has yet to be clearly established and represents a major barrier to a system for routine information provision. There were multiple though varying factors identified across Scottish ICUs as limiting the provision of rehabilitation within the ICU. Optimising the management of sedation, analgesia and delirium may help improve patient co-operation with rehabilitation and thus outcome.31-35 Certain factors, such as insufficient staff and equipment, may be modifiable; however, in the current fiscal climate extra resources are unlikely to be provided with the current levels of evidence available. There appears to be homogeneity across Scottish ICUs regarding the provision of the low intensity physical therapies (eg limb stretching). There was a statistically significant difference however in the percentage of ICUs routinely providing more intensive rehabilitation therapies to patients with an endotracheal tube compared to those who are extubated or have a tracheostomy. This difference may reflect
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an actual difference in practice, perhaps relating to concern regarding the early mobilisation of critically ill patients, or may simply reflect the subjective answers to the questioning. However, if the former is the case, studies36,37 have not only demonstrated the safety of these therapies in patients with an endotracheal tube but also a benefit on a variety of short-term outcomes,32,38 meaning therefore that some patients are not benefitting from potentially efficacious therapies. Although in only a single study,32 incorporation of ADLs (eg bathing, grooming, dressing, eating) into routine rehabilitation was shown to be beneficial; however, few Scottish units do this. Few ICU patients are likely to be able to undertake most ADLs in the early stages of their admission though many should be able to undertake at least some as they recover. The barriers to routine implementation of more intensive physical therapies incorporating ADLs in Scottish ICUs needs further clarification and intervention. There are limitations to our survey which include the following: the relatively small number of healthcare professionals surveyed; the subjective nature of many of the questions; the semi-quantitative nature of our survey rather than a quantitative service evaluation; and evaluation of groups of sequelae together rather than individually. We chose to survey the ICU lead clinicians and lead physiotherapists because we believed these individuals would have a wellinformed opinion of the practices within their ICU. The telephone survey design was chosen to maximise the survey response rate, acknowledging the surveys detail. However this methodology potentially introduces interview bias both through respondent bias, such as courtesy bias or exaggeration, and/or interviewer bias through for example failure to deliver the questions as printed in the questionnaire. The two interviewers attempted to minimise interviewer bias through reading the questions directly from the questionnaire. The phrasing of the survey questions may also introduce bias to our findings. While it was explained to all those surveyed that the aim of the survey was to identify practice in their ICU, some questions were expressed do you while others were in your ICU This potentially may have resulted in a greater influence of an individuals own practice in some questions and thus these answers being less representative of the ICUs practice as a whole. The NICE clinical guideline has provided a much-needed framework for best practice in rehabilitation after critical illness although its practical application is severely constrained by a lack of evidence-based assessment tools, diagnoses/ terminology and interventions. Future work in this area will include a quantitative service evaluation of routine practice, validation of diagnostic criteria and assessment tools, and the evaluation of rehabilitation therapies within the context of clinical trials. No conflicts of interest to declare and no financial support received.

References
1. Scottish Intensive Care Society Audit Group. Audit of critical care in Scotland 2010 Reporting on 2009, 2010. Available from: http:// www.sicsag.scot.nhs.uk/Publications/Main.htm Accessed 20th April 2011. 2. Intensive Care National Audit and Research Centre (ICNARC). CMP

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case mix and outcome summary statistics, 2010. Available from: https://www.icnarc.org/documents/summary%20statistics%202008-9.pdf Accessed 20th April 2011. 3. Herridge MS, Cheung AM, Tansey CM et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003;348:683-93. 4. Chaboyer W, Grace J. Following the path of ICU survivors: A qualityimprovement activity. Nurs Crit Care 2003;8:149-55. 5. Van der Schaaf M, Beelen A, Dongelmans DA et al. Poor functional recovery after a critical illness: a longitudinal study. J Rehabil Med 2009;41:1041-48. 6. Davydow GS, Gifford JM, Desai DV et al. Depression in general intensive care unit survivors: a systematic review. Intensive Care Med 2009;35:796-809. 7. Davydow DS, Desai SV , Needham DM, Bienvenu OJ. Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review. Psychosom Med 2008;70:512-19. 8. Davydow DS, Gifford JM, Desai SV et al. Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. Gen Hosp Psychiatry 2008;30:421-34. 9. Hopkins RO, Weaver LK, Collingridge D et al. Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med 2005;171:340-47. 10. National Institute for Health and Clinical Excellence (NICE). NICE clinical guideline 83: Rehabilitation after critical illness, 2009. Available from: http://www.nice.org.uk/CG83 Accessed 20th April 2011. 11. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317-22. 12. Levy MM, Dellinger RP , Townsend SR et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med 2010;36:222-31. 13. Cabana MD, Rand CS, Powe NR et al. Why dont physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458-65. 14. Scottish Intercollegiate Guidelines Network. SIGN Clinical Guidelines Numerical List. Available from: http://www.sign.ac.uk/guidelines/ published/numlist.html Accessed 20th April 2011. 15. Scottish Intensive Care Society. Guidelines for use of activated protein C: NICE guidelines supersede SICS guideline of November 2002, 2008. Available from: http://www.scottishintensivecare.org.uk/sics/ research/APC.pdf Accessed 20th April 2011. 16. Stevens RD, Marshall SA, Cornblath DR et al. A framework for diagnosing and classifying intensive care unit-acquired weakness. Crit Care Med 2009;37[Suppl.]:S299-S308. 17. National Clinical Guideline Centre (NCGC). Clinical Guideline 103 Delirium: diagnosis, prevention and management, 2010. Available from: http://guidance.nice.org.uk/CG103/Guidance/pdf/English Accessed 20th April 2011. 18. Ely EW, Inouye SK, Bernard GR et al. Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the intensive care unit (CAM-ICU). JAMA 2001;286:2703-10. 19. Ely EW, Margolin R, Francis J et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the intensive care unit (CAM-ICU). Crit Care Med 2001;29:1370-79. 20. Ely EW, Shintani A, Truman B et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004;291:1753-62. 21. De Jonghe B, Sharshar T, Lefaucheur JP et al. Paresis acquired in the intensive care unit: A prospective multicentre study. JAMA 2002;288: 2859-67. 22. Ali NA, OBrien JM, Hoffman SP et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med 2008;178:261-68. 23. Fan E, Ciesla ND, Truong AD et al. Inter-rated reliability of manual

muscle strength testing in ICU survivors and simulated patients. Intensive Care Med 2010;36:1038-43. 24. Sawdon V , Woods I, Proctor M. Post-intensive care interviews: implications for future practice. Intensive Crit Care Nurs 1995;11:329-32. 25. Fan E, Shahid S, Kondreddi P et al. Informed consent in the critically ill: a two-step approach incorporating delirium screening. Crit Care Med 2008;36:94-99. 26. Knowles RE, Tarrier N. Evaluation of the effect of prospective patient diaries on emotional well-being in intensive care unit survivors: A randomized controlled trial. Crit Care Med 2009;37:184-91. 27. Database of Individual Patient Experiences (DIPEx). Intensive care: patients experiences, 2006. Available from: http:// www.healthtalkonline.org/Intensive_care/Intensive_care_Patients_ experiences Accessed 20th April 2011. 28. Database of Individual Patient Experiences (DIPEx). Intensive care: experiences of family & friends, 2007. Available from: http:// www.healthtalkonline.org/Intensive_care/Intensive_care__experiences_of_ family__friends Accessed 20th April 2011. 29. Jones C, Skirrow P , Griffiths RD et al. Rehabilitation after critical illness: a randomized, controlled trial. Crit Care Med 2003;31:2456-61. 30. Cuthbertson BH, Rattray J, Campbell MK et al The PRaCTICaL study of a nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial. BMJ 2009;339:b3723. 31. Kress JP , Pohlman AS, OConnor MF , Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000;342:1471-77. 32. Schweickert WD, Pohlman MC, Pohlman AS et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373:1874-82. 33. Chanques G, Jaber S, Barbotte E et al. Impact of systemic evaluation of pain and agitation in an intensive care unit. Crit Care Med 2006;34: 1691-99. 34. Payen J-F , Bosson J-L, Chanques G et al for the DOLOREA investigators. Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: A post hoc analysis of the DOLOREA study. Anesthesiology 2009;111:1308-16. 35. Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 2010;375:475-80. 36. Stiller K, Phillips AC, Lambert P. The safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care patients. Physiother Theory Practice 2004;20:175-85. 37. Bailey PR, Thomsen GEM, Spuhler VJR et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007;35:139-45. 38. Morris PE, Goad A, Thompson C et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36:2238-43.

Richard TD Appleton Clinical Lecturer and Specialty Registrar, Section of Anaesthesia, Pain and Critical Care Medicine rtdappleton@doctors.org.uk Mairianne MacKinnon Specialty Registrar, Department of
Anaesthesia

Malcolm G Booth Consultant, Department of Anaesthesia Julie Wells Specialist Physiotherapist, Department of
Physiotherapy

Tara Quasim Senior Lecturer and Consultant, Section of


Anaesthesia, Pain and Critical Care Medicine University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK

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Appendix 1

Questionnaire A Medical staff (please circle where appropriate)

1. Are you aware of NICE clinical guideline No. 83: Rehabilitation after critical illness? Yes 2. Do you formally assess: a. Physical dimension? i. Physical problems ii. Sensory problems iii. Communication problems iv. Social care or equipment needs b. Non-physical dimensions? i. Anxiety i. Depression ii. Post-traumatic stress-related symptoms iii. Behavioural and cognitive problems iv. Psychosocial problems c. If yes to any above, how in particular do you assess each relevant problem? On ICU D/C Other No time point No

viii.Problems setting combined goals/ plans between the MDT members ix.Other (please state)

Yes

No

Dont know

5. Information to patients, families/carers and GPs a. Do you routinely provide information regarding a patients critical illness and treatments to i. The patient? Yes No Dont know Written Verbal

ii. The patients family &/or carer? Yes No Dont know

iii. The patients GP? Yes No Dont know

b. Where applicable do you routinely provide information regarding short-term and long-term physical and non-physical problems which may require rehabilitation to? i. The patient? Yes No Dont know Written Verbal

ii. The patients family &/or carer? Yes No Dont know

iii. The patients GP? Yes No Dont know

3. Have you received funding for rehabilitation for your ICU patients? Yes No Dont know

6. On discharge from ICU are patients &/or their families/carers given information regarding: a. The differences between critical care and ward based care? Yes No Dont know

4. Level of rehabilitation in ICU a. Do you feel your patients would benefit from greater rehabilitation whilst in ICU? Yes No Dont know

b. The transfer of clinical responsibility to a different medical team? Yes No Dont know

7. NICE guidelines 83: Rehabilitation after critical illness a. Do you feel the current NICE guideline is useful? Yes No Dont know

b. What are the limitations to rehabilitation in your ICU? i. Lack of patient co-operation ii. Sedation iii. Severity of illness of patients iv. Insufficient physiotherapy availability v. Insufficient ancillary staff vi.Insufficient equipment vii.Insufficient funding Yes Yes Yes Yes Yes Yes Yes No No No No No No No Dont know Dont know Dont know Dont know Dont know Dont know Dont know

8. Do you have any other comments regarding NICE guidelines 83: Rehabilitation after critical illness?

9. Do you have any other comments regarding rehabilitation in ICU?

Questionnaire B Physiotherapy staff (please circle where appropriate) 1. Are you aware of NICE clinical guideline No. 83: Rehabilitation after critical illness? Yes No d. Positioning (limb &/or full body)? e. Sitting over bed-side i. While intubated? ii. Only once extubated/trached? f. Sitting up in chair i. While intubated? ii. Only once extubated/trached? Yes Yes No No Yes Yes No No Yes No

2. What rehabilitation do patients routinely receive while in your ICU: a. Respiratory physiotherapy? b. Limb stretching (active &/or passive)? c. Strengthening exercises? Yes Yes Yes No No No

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g. Standing up i. While intubated? ii. Only once extubated/trached? h. Mobilising on feet i. Whilst intubated? ii. Only once extubated/trached? i. Splinting? j. Cycle ergometry? k. Other (please state)? Yes Yes Yes Yes No No No No Yes Yes No No

6. Documentation a. What format does rehabilitation documentation take: i. Booklet? ii. Continuation sheets in clinical records? iii. Other (please state)? b. Are patients rehabilitation requirements specifically documented? Yes No Dont know Yes Yes No No Dont know Dont know

c. Are patients rehabilitation goals specifically documented? 3. Do patients whilst in ICU routinely get set: a. Short-term rehabilitation goals: Yes No Dont know Yes No Dont know

d. Are these rehabilitation requirements/goals specifically discussed with the rest of the MDT? Yes No Dont know

b. Medium-term rehabilitation goals: Yes No Dont know

c. If Yes to either question 3a or b, are patients families included in setting these goals: Yes Definitions: Short-term goals: Goals for the patient to reach before they leave hospital. Medium-term goals: Goals to help the patient return to their normal ADLs after discharge from hospital. 4. Do patients in your ICU routinely receive an individualised, structured rehabilitation programme? Yes No Dont know No Dont know

7. On discharge from ICU are the patients rehabilitation requirements formally handed over? Yes No Dont know

8. Are you involved in reviewing patients 2-3 months following ICU discharge? Yes 9. Outcome measures a. Do you use any outcome measures to assess the physical dimensions of rehabilitation in ICU or following discharge from ICU? Yes No Dont know No Dont know

5. Are activities of daily living (ADLs) integrated into patients current rehabilitation in your ICU? Yes No Dont know

b. If yes to question 9a, which outcome measures do you use (please state)?

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