× NICE uses cookies to make the site better.  Learn more
A-Z
Topics
Latest

Rehabilitation after critical illness

About

What is covered

This interactive flowchart covers rehabilitation of adults after critical illness.
To the non-specialist, the terminology around critical illness can be confusing. Critical care is now used as a term that encompasses intensive care or intensive therapy provided in intensive care units (ICUs) or intensive therapy units (ITUs), together with what used to be called high-dependency care provided in high-dependency units (HDUs). Intensive care, or level 3 care, generally involves the support of one or more failing organ systems, usually including the lungs, whereas high dependency care, or level 2 care, supports one system. Recently the distinctions have become blurred, hence the increasing use of the term critical care.
Approximately 110,000 people spend time in critical care units in England and Wales each year, the majority surviving to be discharged home. Research on the longer-term consequences of critical illness has shown that significant numbers of patients surviving critical illness have important continuing problems. For many, discharge from critical care is the start of an uncertain journey to recovery characterised by, among other problems, weakness, loss of energy and physical difficulties, anxiety, depression, post-traumatic stress (PTS) phenomena and, for some, a loss of mental faculty (termed cognitive function).

Updates

Updates to this interactive flowchart

6 September 2017 Rehabilitation after critical illness in adults (NICE quality standard 158) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on rehabilitation for adults after critical illness in an interactive flowchart

What is covered

This interactive flowchart covers rehabilitation of adults after critical illness.
To the non-specialist, the terminology around critical illness can be confusing. Critical care is now used as a term that encompasses intensive care or intensive therapy provided in intensive care units (ICUs) or intensive therapy units (ITUs), together with what used to be called high-dependency care provided in high-dependency units (HDUs). Intensive care, or level 3 care, generally involves the support of one or more failing organ systems, usually including the lungs, whereas high dependency care, or level 2 care, supports one system. Recently the distinctions have become blurred, hence the increasing use of the term critical care.
Approximately 110,000 people spend time in critical care units in England and Wales each year, the majority surviving to be discharged home. Research on the longer-term consequences of critical illness has shown that significant numbers of patients surviving critical illness have important continuing problems. For many, discharge from critical care is the start of an uncertain journey to recovery characterised by, among other problems, weakness, loss of energy and physical difficulties, anxiety, depression, post-traumatic stress (PTS) phenomena and, for some, a loss of mental faculty (termed cognitive function).

Updates

Updates to this interactive flowchart

6 September 2017 Rehabilitation after critical illness in adults (NICE quality standard 158) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Rehabilitation after critical illness in adults

These quality statements are taken from the rehabilitation after critical illness in adults quality standard. The quality standard defines clinical best practice for rehabilitation after critical illness in adults and should be read in full.

Quality statements

Rehabilitation goals

This quality statement is taken from the rehabilitation after critical illness in adults quality standard. The quality standard defines clinical best practice for rehabilitation after critical illness in adults and should be read in full.

Quality statement

Adults in critical care at risk of morbidity have their rehabilitation goals agreed within 4 days of admission to critical care or before discharge from critical care, whichever is sooner.

Rationale

Adults in critical care who are at risk of developing physical and non-physical morbidity need a comprehensive assessment to establish their rehabilitation needs and to put a rehabilitation plan in place. Rehabilitation goals need to be agreed with the person as early as possible to inform the rehabilitation programme. Starting rehabilitation early can improve physical and non-physical functioning and prevent future problems. The needs of a person in critical care can change very quickly, therefore goals should be continually reviewed and updated within the rehabilitation programme.

Quality measures

Structure
a) Evidence of local systems to flag when adults in critical care are at risk of morbidity.
Data source: Local data collection, for example, review of patient hospital records.
b) Evidence of local arrangements to ensure that adults in critical care at risk of morbidity have rehabilitation goals agreed and documented.
Data source: Local data collection, for example, review of patient hospital records.
Process
Proportion of adults in critical care at risk of morbidity who have their rehabilitation goals agreed within 4 days of being admitted to critical care or before discharge from critical care, whichever is sooner.
Numerator – the number in the denominator who have their rehabilitation goals agreed within 4 days of being admitted to critical care or before discharge from critical care, whichever is sooner.
Denominator – the number of adults in critical care who are at risk of morbidity.
Data source: Local data collection, for example, review of patient hospital records.
Outcome
Levels of satisfaction with involvement in their own care among adults in critical care.
Data source: Local data collection, for example, surveys of patients and their families.

What the quality statement means for different audiences

Service providers (hospitals) ensure that critical care pathways support identifying adults at risk of morbidity through a short clinical assessment and that all those identified as being at risk have a further comprehensive clinical assessment. Service providers put arrangements in place to ensure that adults’ rehabilitation goals are based on the comprehensive clinical assessment and agreed within 4 days of being admitted to critical care or before discharge from critical care, whichever is sooner.
Healthcare professionals with experience in critical care and rehabilitation (such as intensive care professionals or other professionals with access to referral pathways) agree rehabilitation goals for adults in critical care who are at risk of morbidity, within 4 days of critical care admission or before critical care discharge, whichever is sooner. They ensure that goals are agreed with the patient if possible, reviewed and updated throughout rehabilitation. Family or carers may be involved if the person agrees; they will be involved if the person is unconscious or unable to give their agreement for treatment (formal consent).
Commissioners (clinical commissioning groups and NHS England) ensure that they commission critical care services which use a comprehensive clinical assessment to identify adults at risk of morbidity and establish their rehabilitation goals. They monitor the providers to ensure that this is done within 4 days of critical care admission or before discharge from critical care, whichever is sooner, reviewed and updated throughout rehabilitation.
Adults in critical care who are likely to benefit from more support have a thorough assessment to identify what might help them to recover (their rehabilitation needs). If they can, they talk with their healthcare team about how they hope they might recover and what they want to achieve (their rehabilitation goals), and then these goals are written in their notes. Family or carers may be involved if the person is happy with this; they will be involved if the person is unconscious or unable to give their agreement for treatment (formal consent). Goals should be agreed within 4 days of a person arriving in critical care, or earlier if they stay in critical care for less than 4 days.

Source guidance

Rehabilitation after critical illness in adults (2009) NICE guideline CG83, recommendation 1.4 and expert opinion

Definitions of terms used in this quality statement

Adults in critical care at risk of morbidity
People’s risk of morbidity should be identified in a short clinical assessment that includes physical and non-physical elements. Examples include:
  • Physical
    • Anticipated long duration of critical care stay.
    • Obvious significant physical or neurological injury.
    • Unable to self-ventilate on 35% oxygen or less.
    • Presence of premorbid respiratory or mobility problems.
    • Risk or presence of malnutrition, changes in eating patterns, poor or excessive appetite, inability to eat or drink.
    • Unable to get in and out of bed independently.
    • Unable to mobilise independently over short distances.
  • Non-physical
    • Recurrent nightmares, particularly where patients report trying to stay awake to avoid nightmares.
    • Intrusive memories of traumatic events that have occurred before admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks).
    • Acute stress reactions, including symptoms of new and recurrent anxiety, panic attacks, fear, low mood, anger or irritability in the critical care unit.
    • Hallucinations, delusions and excessive worry or suspiciousness.
    • Expressing the wish not to talk about their illness or changing the subject quickly to another topic.
    • Lack of cognitive functioning to continue to exercise independently.
[Adapted from NICE’s guideline on rehabilitation after critical illness in adults, recommendation 1.2, table 1 and expert opinion]
Rehabilitation goals
Rehabilitation goals can be short, medium or long term and will change throughout the patient’s recovery from critical illness. They can be physical as well as psychological. Goals will need to be achievable and based on regular patient assessment of physical and non-physical consequences of the critical illness throughout their recovery.
For example, in the critical care unit, reduced mobility, weakness and fatigue will be the main problems, for which the overall goal will be early mobilisation. A short-term goal might be for the patient to be able to sit on the edge of the bed with support, a medium-term goal to stand aided and a long-term goal to march on the spot or take a few supported steps. Later, on the ward, reduced mobility will continue, but the goals will change; a short-term goal might be to walk to the toilet and a long-term goal to manage the stairs before discharge.
[Expert opinion]

Transfer from critical care to a general ward

This quality statement is taken from the rehabilitation after critical illness in adults quality standard. The quality standard defines clinical best practice for rehabilitation after critical illness in adults and should be read in full.

Quality statement

Adults at risk of morbidity have a formal handover of care, including their agreed individualised structured rehabilitation programme, when they transfer from critical care to a general ward.

Rationale

Continuity of rehabilitation is very important because any breaks or gaps can set back or slow down recovery. A formal documented handover of care which includes the individualised, structured rehabilitation programme ensures that the general ward team understands the person’s specific physical and non-physical rehabilitation needs, the goals they are working towards and how best to support them. This should ensure continuity of care and improve the person’s experience of transfer from critical care to a general ward.

Quality measures

Structure
a) Evidence of formal handover processes between team discharging adults at risk of morbidity from critical care and team admitting them to a general ward.
Data source: Local data collection, for example, critical care discharge and ward admission protocols.
b) Evidence of local arrangements to ensure that the structured rehabilitation programme is included in the formal handover between the critical care team and the team admitting adults to a general ward.
Data source: Local data collection, for example, critical care discharge and ward admission protocols.
Process
a) Proportion of adults at risk of morbidity who have a formal handover of care when transferring from critical care to a general ward.
Numerator – the number in the denominator who have a formal handover of care.
Denominator – the number of adults at risk of morbidity transferring from critical care to a general ward.
Data source: Local data collection, for example, review of patient hospital records or observation in practice (to check for verbal handover).
b) Proportion of adults at risk of morbidity transferring from critical care to a general ward whose formal handover of care includes their individualised, structured rehabilitation programme.
Numerator – the number in the denominator whose handover of care includes their individualised, structured rehabilitation programme.
Denominator – the number of adults at risk of morbidity transferring from critical care to a general ward who have a formal handover of care.
Data source: Local data collection, for example, review of patient hospital records.
Outcome
Level of satisfaction with continuity of care for adults who are discharged from critical care to a general ward.
Data source: Local data collection, for example, a patient survey.

What the quality statement means for different audiences

Service providers (hospitals) have procedures in place to ensure a formal handover of care takes place that includes the individualised, structured rehabilitation programme for adults at risk of morbidity transferring from critical care to a general ward. Handover should include members of multidisciplinary teams from critical care and the general ward.
Healthcare professionals (such as doctors, nurses, specialists in rehabilitation medicine, physiotherapists, psychologists, occupational therapists, speech and language therapists and dietitians) from critical care and the general ward work together in a formal handover of care, which includes the individualised, structured rehabilitation programme, when adults at risk of morbidity transfer from critical care to a general ward.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which members of multidisciplinary teams from critical care and the general ward work in an integrated way that ensures continuity of care and an uninterrupted support for adults at risk of morbidity when they transfer to a general ward.
Adults leaving critical care who are at risk of long-term problems have information about all of their needs (physical, psychological, emotional, sensory and communication) transferred to staff on the general ward by the team from critical care. This means the ward team understands what might help the person to recover (their rehabilitation needs). Adults should also have their condition explained to them, and to their family or carers if this is appropriate, and be encouraged to get involved in making decisions about their care.

Source guidance

Definitions of terms used in this quality statement

Adults in critical care at risk of morbidity
People’s risk of morbidity should be identified in a short clinical assessment that includes physical and non-physical elements. Examples include:
  • Physical
    • Anticipated long duration of critical care stay.
    • Obvious significant physical or neurological injury.
    • Unable to self-ventilate on 35% oxygen or less.
    • Presence of premorbid respiratory or mobility problems.
    • Risk or presence of malnutrition, changes in eating patterns, poor or excessive appetite, inability to eat or drink.
    • Unable to get in and out of bed independently.
    • Unable to mobilise independently over short distances.
  • Non-physical
    • Recurrent nightmares, particularly where patients report trying to stay awake to avoid nightmares.
    • Intrusive memories of traumatic events that have occurred before admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks).
    • Acute stress reactions including symptoms of new and recurrent anxiety, panic attacks, fear, low mood, anger or irritability in the critical care unit.
    • Hallucinations, delusions and excessive worry or suspiciousness.
    • Expressing the wish not to talk about their illness or changing the subject quickly to another topic.
    • Lack of cognitive functioning to continue to exercise independently.
[Adapted from NICE’s guideline on rehabilitation after critical illness in adults, recommendation 1.2, table 1 and expert opinion]
Formal handover of care
The handover of care on transfer from critical care to a general ward is the shared responsibility of the critical care team and the ward team.
The formal handover of care should be structured and should include:
  • a summary of the critical care stay, including diagnosis and treatment
  • a monitoring and investigation plan
  • a plan for ongoing treatment, including drugs and therapies, nutrition plan, infection status and any agreed limitations of treatment
  • an agreed individualised structured rehabilitation programme, including physical, psychological, emotional and cognitive needs
  • specific communication or language needs.
[Adapted from NICE’s guideline on acutely ill adults in hospital, recommendation 1.15 and expert opinion]
Individualised, structured rehabilitation programme
The individualised, structured rehabilitation programme should address rehabilitation needs based on the comprehensive clinical assessment done in a critical care unit and identify the most recent goals agreed with the patient. The programme should be developed and delivered by members of a multidisciplinary team, and should include appropriate referrals, if applicable.
[Adapted from NICE’s guideline on rehabilitation after critical illness in adults, recommendations 1.16 and 1.17]

Information on discharge from hospital

This quality statement is taken from the rehabilitation after critical illness in adults quality standard. The quality standard defines clinical best practice for rehabilitation after critical illness in adults and should be read in full.

Quality statement

Adults who were in critical care and at risk of morbidity are given information based on their rehabilitation goals before they are discharged from hospital.

Rationale

Discussions about what to expect after discharge should be happening as adults who were in critical care and at risk of morbidity continue to recover in hospital. Moving from hospital to a home environment can be difficult and cause a lot of anxiety. It is important to make information relevant to the person and their situation. They should know how to continue working towards the goals they set out while in hospital and who to contact if they need any support. This information should be given to the person and to family members or carers if the person agrees.

Quality measures

Structure
Evidence of local arrangements to provide adults who are discharged from hospital after a critical care stay with information relevant to their individual needs and rehabilitation goals.
Data source: Local data collection, for example, hospital discharge protocols.
Process
Proportion of adults who were in critical care and at risk of morbidity who are given information on hospital discharge based on the rehabilitation goals agreed during their hospital stay.
Numerator – the number in the denominator who are given information based on the rehabilitation goals agreed during their hospital stay.
Denominator – the number of adults who were in critical care and at risk of morbidity discharged from hospital.
Data source: Local data collection, for example, an audit of patient hospital records.
Outcome
Levels of satisfaction with information that was relevant to recovery at home among adults who were discharged from hospital following a critical care stay.
Data source: Local data collection, for example, a patient and carer satisfaction survey.

What the quality statement means for different audiences

Service providers (hospitals) have protocols in place to ensure that adults who were in critical care and at risk of morbidity are given information about what to expect after discharge from hospital. The information is based on the rehabilitation goals agreed during the hospital stay. If the person agrees, this information can also be given to their family or carer.
Healthcare professionals (members of the team responsible for discharge) give adults who were in critical care and at risk of morbidity information about what to expect after discharge from hospital. The information is based on the rehabilitation goals agreed during the hospital stay. If the person agrees, this information can also be given to their family or carer.
Commissioners (clinical commissioning groups) ensure that the services they commission have arrangements in place to give adults who were in critical care and at risk of morbidity information about what to expect after discharge from hospital. The information is based on the rehabilitation goals agreed during the hospital stay. If the person agrees, this information can also be given to their family or carer.
Adults who were in critical care and at risk of long-term health problems are given information about what to expect when they leave hospital. This should explain what they can do to help their recovery and what other things they might face during this period. If they agree, this information can also be given to their family or carer.

Source guidance

Rehabilitation after critical illness in adults (2009) NICE guideline CG83, recommendation 1.22

Definitions of terms used in this quality statement

Adults in critical care at risk of morbidity
People’s risk of morbidity should be identified in a short clinical assessment that includes physical and non-physical elements. Examples include:
  • Physical
    • Anticipated long duration of critical care stay.
    • Obvious significant physical or neurological injury.
    • Unable to self-ventilate on 35% oxygen or less.
    • Presence of premorbid respiratory or mobility problems.
    • Risk or presence of malnutrition, changes in eating patterns, poor or excessive appetite, inability to eat or drink.
    • Unable to get in and out of bed independently.
    • Unable to mobilise independently over short distances.
  • Non-physical
    • Recurrent nightmares, particularly where patients report trying to stay awake to avoid nightmares.
    • Intrusive memories of traumatic events that have occurred before admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks).
    • Acute stress reactions including symptoms of new and recurrent anxiety, panic attacks, fear, low mood, anger or irritability in the critical care unit.
    • Hallucinations, delusions and excessive worry or suspiciousness.
    • Expressing the wish not to talk about their illness or changing the subject quickly to another topic.
    • Lack of cognitive functioning to continue to exercise independently.
[Adapted from NICE’s guideline on rehabilitation after critical illness in adults, recommendation 1.2, table 1 and expert opinion]
Information
The following information should be given before discharge:
  • Information about physical and cognitive recovery and rate of recovery, based on the rehabilitation goals set during ward-based care, if applicable.
  • Information about psychological and emotional recovery, including symptoms that frequently occur in the months after critical illness (for example, low mood, anxiety, flashbacks and nightmares, changes or conflict in relationships).
  • If applicable, information about diet and any other continuing treatments.
  • Information about how to manage activities of daily living, including self-care and re-engaging with everyday life.
  • If applicable, information about driving, returning to work, housing and benefits.
  • Information about local statutory and non-statutory support services, such as support groups.
  • General guidance, especially for the family or carers, on what to expect and how to support the person at home. This should take into account both the person's needs and the family's or carers’ needs.
The person should be given their own copy of the critical care discharge summary.
[Adapted from NICE’s guideline on rehabilitation after critical illness in adults, recommendation 1.22 and expert opinion]

Equality and diversity considerations

People who do not speak or read English well may be at a disadvantage, particularly because of the complex language used in critical care. Translators should be available if needed to ensure that people understand the information given to them. Arrangements should be made to account for the extra time that this may require.

Follow-up after critical care discharge

This quality statement is taken from the rehabilitation after critical illness in adults quality standard. The quality standard defines clinical best practice for rehabilitation after critical illness in adults and should be read in full.

Quality statement

Adults who stayed in critical care for more than 4 days and were at risk of morbidity have a review 2 to 3 months after discharge from critical care.

Rationale

Follow-up is needed for adults who were in critical care for more than 4 days and at risk of morbidity, because further needs may become apparent after discharge. A review to reassess health and social care needs 2 to 3 months after discharge from critical care ensures that any new physical or non-physical problems are identified and further support is arranged as needed. Some adults who were in critical care for 4 days or less may also experience problems that need a review. Also, problems may emerge more than 3 months after discharge. The lifelong impact of a stay in critical care means that all adults who have experienced this should be able to self-refer and be reassessed at any time.

Quality measures

Structure
Evidence of local follow-up arrangements for adults who had a critical care stay of more than 4 days and were at risk of morbidity.
Data source: Local data collection, for example, critical care discharge protocols.
Process
Proportion of adults who were in critical care for more than 4 days and at risk of morbidity, who have a review between 2 and 3 months after discharge from critical care.
Numerator – the number in the denominator who have a review between 2 and 3 months after discharge from critical care.
Denominator – the number of adults who were in critical care for more than 4 days and at risk of morbidity, who have been discharged from critical care.
Data source: Local data collection, for example, an audit of patient hospital records.
Outcome
a) Number of physical problems identified within 3 months of discharge from critical care.
Data source: Local data collection, for example, an audit of patient records.
b) Number of non-physical problems identified within 3 months of discharge from critical care.
Data source: Local data collection, for example, an audit of patient records.
c) Levels of satisfaction with support received to manage rehabilitation needs among adults discharged from critical care.
Data source: Local data collection, for example, a patient survey.

What the quality statement means for different audiences

Service providers (hospitals) have pathways in place to ensure that adults who stay in critical care for more than 4 days and are at risk of morbidity have a review 2 to 3 months after discharge from critical care to review their recovery and rehabilitation outcomes. They should also have arrangements in place to allow adults who have had a critical care stay to self-refer and be reassessed at any time.
Healthcare professionals (such as nurses, intensive care professionals, specialists in rehabilitation medicine, physiotherapists and clinical psychologists working in critical care follow-up clinics) carry out a review 2 to 3 months after discharge from critical care for adults who were in critical care for more than 4 days and at risk of morbidity. They do this by completing a rehabilitation assessment/questionnaire which includes functional reassessment of health and social care needs. The review can be either in the community or hospital. They also ensure that any adult who has had a critical care stay can be reassessed if they self-refer at any time.
Commissioners (clinical commissioning groups) ensure that they commission services that follow up adults who were in critical care for more than 4 days and at risk of morbidity with a review 2 to 3 months after discharge from critical care. They also ensure that services accept and reassess all adults who have had a critical care stay if they self-refer at any time after discharge.
Adults who were in critical care for more than 4 days and at risk of long-term problems have a review by a healthcare professional 2 to 3 months after leaving critical care to talk about their recovery and any problems they might have. These might include physical, cognitive, psychological, emotional, sensory or communication problems. At the meeting they should also talk about any social care or equipment needs so that extra support can be arranged if needed. All adults who have been in critical care should be able to attend a critical care follow-up clinic if they feel they need it.

Source guidance

Rehabilitation after critical illness in adults (2009) NICE guideline CG83, recommendations 1.1 and 1.23

Definitions of terms used in this quality statement

Adults in critical care at risk of morbidity
People’s risk of morbidity should be identified in a short clinical assessment that includes physical and non-physical elements. Examples include:
  • Physical
    • Anticipated long duration of critical care stay.
    • Obvious significant physical or neurological injury.
    • Unable to self-ventilate on 35% oxygen or less.
    • Presence of premorbid respiratory or mobility problems.
    • Risk or presence of malnutrition, changes in eating patterns, poor or excessive appetite, inability to eat or drink.
    • Unable to get in and out of bed independently.
    • Unable to mobilise independently over short distances.
  • Non-physical
    • Recurrent nightmares, particularly where patients report trying to stay awake to avoid nightmares.
    • Intrusive memories of traumatic events that have occurred before admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks).
    • Acute stress reactions including symptoms of new and recurrent anxiety, panic attacks, fear, low mood, anger or irritability in the critical care unit.
    • Hallucinations, delusions and excessive worry or suspiciousness.
    • Expressing the wish not to talk about their illness or changing the subject quickly to another topic.
    • Lack of cognitive functioning to continue to exercise independently.
[Adapted from NICE’s guideline on rehabilitation after critical illness in adults, recommendation 1.2, table 1 and expert opinion]
Review
A functional reassessment of the adult’s health and social care needs, carried out face to face in the community or in hospital by a healthcare professional with training and skills in rehabilitation after critical care who is familiar with the adult’s critical care problems, rehabilitation goals, individualised structured rehabilitation programme and rehabilitation care pathway. It should include the following physical and non-physical dimensions:
  • physical problems (physical dimension)
  • sensory problems (physical dimension)
  • communication problems (physical dimension and non-physical dimension)
  • social care or equipment needs (physical dimension)
  • anxiety (non-physical dimension)
  • depression and low mood (non-physical dimension)
  • post-traumatic stress-related symptoms (non-physical dimension)
  • behavioural and cognitive problems (non-physical dimension)
  • psychosocial problems (non-physical dimension).
[Adapted from NICE’s guideline on rehabilitation after critical illness in adults, recommendations 1.20, 1.23 and 1.24]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Short clinical assessment examples that may indicate risk of morbidity

Note: this list is not exhaustive and healthcare professionals should use their clinical judgement.

Physical

Unable to get out of bed independently.
Anticipated long duration of critical care stay.
Obvious significant physical or neurological injury.
Lack of cognitive functioning to continue exercise independently.
Unable to self ventilate on 35% of oxygen or less.
Presence of premorbid respiratory or mobility problems.
Unable to mobilise independently over short distances.

Non-physical

Recurrent nightmares, particularly where patients report trying to stay awake to avoid nightmares.
Intrusive memories of traumatic events which have occurred prior to admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks).
New and recurrent anxiety or panic attacks.
Expressing the wish not to talk about their illness or changing the subject quickly off the topic.

Functional assessment symptoms that may indicate morbidity

Physical dimensions

Physical problems: Weakness, inability/partial ability to sit, rise to standing, or to walk, fatigue, pain, breathlessness, swallowing difficulties, incontinence, inability/partial ability to self-care.
Sensory problems: Changes in vision or hearing, pain, altered sensation.
Communication problems: Difficulties in speaking or using language to communicate, difficulties in writing.
Social care or equipment needs: Mobility aids, transport, housing, benefits, employment and leisure needs.

Non-physical dimensions

Anxiety, depression and post-traumatic stress-related symptoms: New or recurrent somatic symptoms including palpitations, irritability and sweating; symptoms of derealisation and depersonalisation; avoidance behaviour; depressive symptoms including tearfulness and withdrawal; nightmares, delusions, hallucinations and flashbacks.
Behavioural and cognitive problems: Loss of memory, attention deficits, sequencing problems, deficits in organisational skills, confusion, apathy, disinhibition, compromised insight.
Other psychological or psychosocial problems: Low-self-esteem, poor or low self-image and/or body image issues, relationship difficulties, including those with the family and/or carer.

Glossary

a brief clinical assessment to identify patients who may be at risk of developing physical and non-physical morbidity
a more detailed assessment to determine the rehabilitation needs of patients who have been identified as being at risk of developing physical and non-physical morbidity
a more detailed assessment to determine the rehabilitation needs of patients who have been identified as being at risk of developing physical and non-physical morbidity
an assessment to examine the patient's daily functional ability
goals for the patient to reach before they are discharged from hospital
goals to help the patient return to their normal activities of daily living after they are discharged from hospital
problems such as muscle loss, muscle weakness, musculoskeletal problems including contractures, respiratory problems, sensory problems, pain, and swallowing and communication problems
psychological, emotional and psychiatric problems, and cognitive dysfunction
multidisciplinary team: a team of healthcare professionals with the full spectrum of clinical skills needed to offer holistic care to patients with complex problems. The team may be a group of people who normally work together or who only work together intermittently

Paths in this pathway

Pathway created: August 2012 Last updated: September 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

Recently viewed