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Transdisciplinary rehabilitation in ICU Consultant Speech and

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Transdisciplinary rehabilitation
in ICU
Sarah Wallace OBE FRCSLT MPH
Consultant Speech and Language Therapist
Wythenshawe Hospital, Manchester
The University of Manchester, UK
25.11.22
 Outline
What is transdisciplinary rehabilitation and why do we need it?
Supporting evidence
Why is it so difficult to implement?
Examples of successes
 Blurred True
roles collaboration
Transdisciplinary
rehabilitation
Rehab is not Patient
When team members disjointed benefit
from different disciplines
engage in cross-
disciplinary care, Prioritise
Not service
teaching and learning patient
priorities
need
Poor transdisciplinary rehabilitation is associated
with worse outcomes
 SLT

Psychol Silo-thinking
Dietitian
ogist

PATIENT
Nurse Physio
Least effective
approach
Multidisciplinary
OT Medic team rehabilitation
 SLT

Family Dietitian
Cross-disciplinary

Psycho
logist PATIENT Physio

Most effective
approach
Transdisciplinary
Nurse Medic
rehabilitation - TD
OT
 Transdisciplinary rehabilitation is like football
It requires effective teamwork and communication
Improving transdisciplinary communication
in the ICU

Standardise formal Empowers effective

Promote team
communication interdisciplinary
communication
processes communication

Diaz et al Crit Care Med 2022

 Why do we need transdisciplinary rehab?

Mortality in ICU is improving

BUT survival is not enough

Functional outcomes
Quality of life
Starting rehab whilst still on life support therapies reduces complications of PICS

‘Early’ - rehabilitation interventions commencing immediately after stabilization of

physiologic derangements, while patients remain on mechanical ventilation and
vasopressor infusions
Early recognition of Early rehab may reduce
critical illness ventilator time, length of
polyneuropathy is ICU stay, improve
important functional outcome

Jang et al Acute Crit Care 2019 Morales et al Chest 2005

Audit of team effectiveness - improved communication, teamwork, goal setting
and information for patients and families
Led to more effective patient goal setting
Improved outcomes, reduced ICU readmission and mortality
Better teamwork and collaboration
 Johns Hopkins Hospital ICU report
Implementing early transdisciplinary rehabilitation programs
result in a 19-22% reduction in ICU length of stay and significant
cost savings
Patients who have transdisciplinary rehabilitation
rate their quality of life better
 Goals of transdisciplinary rehabilitation
 Truly patient centred
 Safe care, fewer complications
 Optimise functional recovery
 Maximise quality of life
 Cost effective, rehabilitation on a continuum, beyond ICU
 Why is transdisciplinary rehabilitation so
difficult?
 Ineffective communication, ICU is an emotionally challenging environment

 Recognise specialist roles BUT threatened by cross-disciplinary working

 No time for communication

 Different teams provide rehab along the pathway from ICU, ward, community
And rehab
pathways are
complex!

Turner-Stokes 2021 JICS 23(3)

 Successful transdisciplinary rehab
Standardise rehabilitation protocols
Patient and family involvement in goals, research
Time for communication
Cross-disciplinary staff training
Cross-disciplinary and profession specific competencies
Leadership support
Standards and guidelines – local, national and international
TRAMS Tracheostomy Review and Management Service – Melbourne, Aus
 Implementation of TD rehab

TD rehabilitation ward rounds on ICU

TD Tracheostomy teams
TD assessment and goal-setting
Personalised Rehabilitation Prescription
TD ICU follow-up clinics – whole team, anyone can lead
Collaborative audit of functional outcomes, post ICU
 Examples of TD rehab in the UK

National Rehabilitation Collaborative (UK)

• Rehabilitation framework, PICUPS screen, national dataset
• All Party Parliamentary Group - raising government awareness, workforce

Improving Tracheostomy Care Project

• Data driven quality improvement
https://ics.ac.uk/guidance/rehabilitation.html
TD goal setting and tracking functional outcomes
 PICUPS TD screen example

Severe Normal
 Examples of TD rehab in the UK
National Rehabilitation Collaborative (UK)
• Rehabilitation framework, PICUPS screen
• All Party Parliamentary Group

Improving Tracheostomy Care Project

• Data driven quality improvement
• Project team
20 UK hospitals

3 year project

Set up transdisciplinary teams, staff

education, patient involvement

18 interventions e.g early SLT, FEES service

FEES Fibreoptic Endoscopic Evaluation of Swallowing

 Monthly tracheostomy
Incidentsafety incidents
count by category by monthover project duration
40 No Harm Temp Harm TH+LoS Perm Harm Resus Death Mean Incident Score Linear (Mean Incident Score) 5

35

Mean incident severity score per month

30

25
3
Count

20

2
15

10

0 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
Month of project
 Ventilator days -0.11 p<0.01
ICU days -0.25 p<0.01
Trachy days -0.35 p<0.01
Hospital days -0.78 p<0.01
Time to cuff deflation reduced - 17 to 10 days (p<0.01)
Time to oral intake reduced
following introduction of early SLT FEES -26 to 9 days (p<0.01)
Results: MDT impact
 Implementation plan by NHS-England
If all UK hospitals use this approach over 2 years
Cost saving £228
million
(CLP 228 billion)
The future of transdisciplinary rehabilitation
Growing numbers of complex patients with
PICS, higher rehab demand
Innovations - electrical brain / muscle
stimulation devices, costly
Cross–disciplinary training e.g VR
More global collaborative research, focus on
functional outcomes!
 Gracias
Acknowledgements
Professor Brendan McGrath, ITC project team, Wythenshawe Hospital Participating patients

sarah.wallace@mft.nhs.uk

sarahwallaceslt
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