ACCCN's Critical Care Nursing

28 S C O P E O F C R I T I C A L C A R E

preparation and education of critical care nurses are avail- points have often been required to support continued
able 31,57,58 that present frameworks to ensure that the cur- registration. This concept has subsequently been imple-
ricula of courses provide adequate content to prepare mented in the UK and Europe. 64
nurses for this specialist nursing role (see Appendices A1
and B2). RISK MANAGEMENT
Nursing has always been a profession that has required
currency of knowledge and clinical skills through con- Managing risk is a high priority in health, and critical care
tinuing education input, because of the rapidly changing is an important risk-laden environment in which the
knowledge base and innovative treatment regimens. manager needs to be on the lookout for potential error,
These changes are occurring at an increasingly rapid rate, harm and medico-legal vulnerability. The recent Sentinel
65
particularly in critical care. The need for critical care Events Evaluation (SEE) study has given an indication
nurses to maintain current, up-to-date knowledge across of this risk for critical care patients. The SEE study was a
a broad range of clinical states has therefore never been 24-hour observational study of 1913 patients in 205 ICUs
more important. Specific issues related to orientation and worldwide, which identified 584 errors causing harm or
continuing education programs are briefly discussed potential harm to 391 patients. The SEE authors con-
below. cluded there was an urgent need for development and
implementation of strategies for prevention and early
65
detection of errors. A second study by the same team
Orientation specifically targeted errors in administration of parenteral
66
The term orientation reflects a range of activities, from a drugs in ICUs. In this study 1328 patients in 113 ICUs
comprehensive unit-based program, attendance at a worldwide were studied for 24 hours; 861 errors affecting
hospital induction program covering the mandatory edu- 441 patients occurred, or 74.5 parenteral drug admini-
cational requirements of that facility, through to familia- stration errors per 100 patient days. The authors con-
risation with the layout of a department. The aim of an cluded that organisational factors such as error reporting
orientation program is the development of safe and effec- systems and routine checks can reduce the risk of such
tive practitioners. 59 errors. 66
Unit-specific orientation should be a formal, structured What is more alarming is that many health practitioners
program of assessment, demonstration of competence do not acknowledge their own vulnerability to error. One
and identification of ongoing educational needs, and study asked airline flight crews (30,000) and health pro-
should be developed to meet the needs of all staff who fessionals (1033 ICU/operating room doctors and nurses,
are new to the unit. Competency-based orientation is of whom 446 were nurses) from five different countries
learner-focused and based on the achievement of core a simple question, ‘Does fatigue affect your (work) per-
67
competencies that reflect unit needs and enable new formance?’, with fascinating results. Of those respond-
employees to function in their role at the completion of ing, the following replied in the affirmative to the
60
the orientation period. The ACCCN Competency Stan- question: pilots and flight crew, 74%; anaesthetists, 53%;
61
dards for Specialist Critical Care Nurses may be used as surgeons, 30% (a figure for nurses’ responses to this ques-
a framework on which to build competency-based orien- tion was not provided in the study). The study also found
tation programs. that only 33% of hospital staff thought errors were
handled appropriately in their hospital and that over
Continuing Education 50% of ICU staff found it hard to discuss errors. 67
In 2003, both the Royal College of Nursing Australia and Governance and management of the critical care environ-
the College of Nursing implemented systems of formally ment requires a multidisciplinary team of senior clinician
recognising professional development, with the awarding managers who understand both the clinical risk and the
of continuing education (CE) points. While professional quality cycles of the environment as well as the executive
development has always been a requirement of continuing requirements for financial and organisational viability.
practice, this process is becoming more formalised. On 1 An astute and careful balance between good clinical gov-
July 2010 the Australian Health Practitioner Regulation ernance and good corporate governance is required to
Agency came into being as a national health practitioner ensure sustainable and appropriate healthcare for all
body. With this, a formal requirement for continuing users. The take-home message in all this is that managers
education or professional development was mandated. in hospitals manage enormous risks with patients, staff
The Nursing and Midwifery Board of Australia, a subgroup and visitors but often do not appreciate their own level
of the above agency, clearly identifies the standard for of vulnerability to error and risk. Yet claims of negligence
continuing professional development of nurses and mid- and charges of incompetence can be as threatening to the
wives. In New Zealand there is an expectation that a manager as they are to the clinician.
62
minimum of 60 hours professional development and 450
hours of clinical practice will be undertaken over a three- NEGLIGENCE
year period for the purposes of registration renewal. 63
The above studies do not necessarily mean that health
Conversely, North American nursing associations have professionals are negligent. Negligence is a legal term that
for many years had formal programs for recognising con- can be proven only in a court. There are four aspects to
tinuing education and awarding CE points. These CE the charge of negligence:

Resourcing Critical Care 29

1. The provider owed a duty of care to the recipient. of strong, dedicated and collaborative leadership from
2. The provider failed to meet that duty, resulting in managers as the key to organisational success in the
a breech of care. critical care setting. (See Chapter 1 for a discussion of
3. The recipient sustained damages (loss) as a result. leadership.)
4. The breech by the provider caused the recipient to
suffer reasonably foreseeable damages. 68 MANAGING INJURY: STAFF, PATIENT
OR VISITOR
Negligence is a technical error that can be proved in a
court, although it does not follow that a negligent person When staff members are injured, the response must be
is incompetent; in fact, many clinicians and managers swift and deliberate. Injury can come in many forms,
have probably been technically negligent, it’s just that involving physical injuries or biological exposures, for
their errors have yet to be discovered! When managing in example. More often, the problems are grievances, such
this context, the best hope is that the frequency of errors as missing out on an opportunity afforded to others (e.g.
or negligent actions will be reduced by putting into place a promotion), feeling marginalised by others, or not
systems that prevent such errors from occurring. 66 getting a preferred roster.
THE ROLE OF LEADERSHIP AND For families and patients, an injury can be physical, such
as a drug error or an iatrogenic infection; however, the
MANAGEMENT injury can also be non-physical, as with complaints about
Managers must also be leaders, and the need to have good lack of timely information, misinformation or rudeness of
leaders and managers is as relevant to critical care as it is staff. In all circumstances a manager needs to intervene
to any other business or clinical entity. Research on proactively to minimise or contain the negativity or harm
organisational structures in ICUs across the USA in the felt by the ‘victim’. Regardless of the cause of the injury, the
1980s and 1990s demonstrated the important role principles governing good risk management are common
70
69
leadership plays in patient care in the ICU. Using APACHE to many situations and are summarised in Box 2.4.
scoring, organisational efficiency and risk-adjusted sur-
vival were measured. High-performing ICUs demon- If an incident does occur, it is always prudent to docu-
strated that actual survival rates exceeded predicted ment the event as soon as possible afterwards and when
survival rates. it is safe to do so. The clinician who discovers and follows
up an incident must document the event, asking the
Further investigation and analysis of the higher- questions that a manager, family member, police officer,
performing units noted that these units had well-defined lawyer or judge might wish to ask. The written account
protocols, a medical director to coordinate activities, provided soon after the event or incident by a person
well-educated nurses and collaboration between nurses closely involved in, or witness to it, will form a very
69
and doctors. Clear and accessible policies and proce- important testimonial in any subsequent investigation
dures to guide staff practice in the ICU setting were also (Table 2.6).
69
highlighted. These need to be in written form, simple Contemporary wisdom in modern health agencies advo-
to read and in a consistent format, evidence-based, easy cates open disclosure: telling the truth to the patient or
to understand and easy to apply. Box 2.3 shows a possible family about why and how an adverse event has
format for clinical policies and protocols.
occurred. 71,72 This practice may be contrary to informed
The latter study showed similar characteristics: they had legal advice and may not preclude legal action against the
a patient-centred culture, strong medical and nursing staff or institution. 73–75 However, openly informing the
leadership, effective communication and coordination, patient/family of what has occurred can regain trust and
and open and collaborative problem solving and conflict
70
management. One cannot underestimate the value


BOX 2.4 Defensive principles to minimise
BOX 2.3 Sample headings to define a policy risk after an incident (patient or staff) 21

● Policy ● Those persons encouraged to participate in decision
● Rationale making are more inclined to ‘own’ the decisions made;
● Procedure therefore, involve them in deciding how the issue is to be
● Statistical reports (e.g. to measure compliance with or tackled and help to make the expectations realistic.
outcome of policy) ● Education of the person in the various aspects of the
● Other information incident/activity will reduce fear and anxiety.
● Contact person ● Explain the range of possible outcomes and where the
● References affected person is currently situated on that continuum.
● Filing instructions ● Provide frequent and accurate updates on the person’s situ-
● Date of issue ation and what is being done to improve that situation.
● Date for review ● Maintain a consistent approach and as far as possible the
● Signature and designation of authorising officer same person should provide such information/feedback.

30 S C O P E O F C R I T I C A L C A R E



TABLE 2.6 Key points when documenting an incident in a patient’s file notes 21

Question Explanation
Where did the incident occur? For example, bedside, toilet, drug room
Were there any pre-event circumstances of significance? For example, short-staffed, no written protocol
Who witnessed the event? Including staff, patient, visitors
What was done to minimise negative effects? For example, extra staff brought to assist, slip wiped up, sign placed on front
of patient chart warning of reaction/sensitivity etc
Who in authority was notified of the incident? Involving a senior, experienced manager/authority should help expedite
immediate and effective action.
Who informed the victim of the event? What was the victim Clear, concise and non-judgmental explanations to victim or representative
told? What was the response? are necessary as soon as possible, preferably from a credible authority
(manager/director).
What follow-up support, counselling and revision occurred? This is important for both victim and perpetrator; ascertain when counselling
occurred and who provided it.
What review systems were commenced to limit recurrence Magistrates and coroners in particular want to know what system changes
of the event? have occurred to limit the recurrence of the event.


respect, and may help to resolve anger and frustration as coordinate the activity without actually demonstrat-
well as to educate all concerned in how such events can ing or implementing their decisions)
be prevented in the future, a right for which many con- ● peer support programs and training of peers, which
sumer advocates are now lobbying. 76 can be informal, where colleagues debrief others who
have had traumatic or confronting experiences (e.g. a
The process of root cause analysis (RCA) can assist the
team to explore in detail the sequence of events and difficult resuscitation, an aggressive or violent attack
system failures that precipitated an incident and help to or a major personal trauma such as a personal family
inform future system reforms to minimise harm. An RCA tragedy); however, there is growing evidence of the
is a generic method of ‘drilling down’ to identify hospital value of a more formalised system of peer support,
system deficiencies that may not immediately be appar- where staff volunteer to make themselves available for
ent, and that may have contributed to the occurrence of training and to provide assistance and a listening ear
a ‘sentinel event’. The general characteristics of an RCA to a colleague in need. In more complex cases, peers
are that it: 77 may suggest that the staff member seek professional
counselling but can still make themselves available as
● focuses on systems and processes, not individual peer support if desired by the affected staff member.
performance
● includes a review of the relevant literature MEASURES OF NURSING WORKLOAD
● examines the event extensively for underlying contrib-
uting causes OR ACTIVITY
● enables procedure and system modifications. Several workload measures 79–86 have been developed in
an attempt to capture the complexity and diversity of
CONTINGENCY PLANS AND REHEARSAL critical care nursing practice (see Table 2.7 for common
In addition to written policies and protocols, and as well instruments). Some hospitals use an electronic care plan
as having well-educated clinical staff, it is always advis- with activity timings to calculate nursing time and work-
able to have back-up systems in place, especially for major load. An Australian instrument, the critical care patient
83
and rare events that may require rapid management and dependency tool (CCPDT), was developed to measure
coordinated responses. Ryan and MacLochlainn suggest nursing costs in the ICU and is still used in some units
87
the following: 78 to document workload, although no further validation
studies have been published since the original research
● a senior manager rostered on call and accessible for in 1993. The most common instruments used in clinical
advice 24/7 practice and research are variants of the therapeutic inter-
● training of managers (not just clinicians) to know vention scoring system (TISS) and the Nursing Activity
how to respond to crises and incidents Scale (NAS) (see Tables 2.7 and 2.8).
● current and easy-to-find policies and protocols, with
specific information for a manager
● rehearsal of major and rare but foreseeable events, THERAPEUTIC INTERVENTION
such as power outage, external disaster and mass casu- SCORING SYSTEM
88
alty influx, and unit evacuation (these can be per- The therapeutic intervention scoring system (TISS) was
formed as simulated events or ‘tabletop’ exercises, initially developed to measure severity of illness and
where people describe how they would respond and related therapeutic activities, but has been widely used as

Resourcing Critical Care 31



TABLE 2.7 Common ICU nursing workload instruments

Instrument Components Scoring/interpretation
84
TISS 1974 , 1983 (USA) 5788/7684 nursing activities related to therapeutic Most ICU patients: 10–60 points
88
interventions; 0–4 points per variable Acuity: class IV (≥40 points); III (20–39); II (10–19); I (<10)
UK ICS 1983 , 2003 86 4 levels of care, with qualitative assessment of organ 0 = routine ward care
85
systems 1 = ward care supported by critical care team
2 = support and monitoring of single organ
dysfunction/failure
3 = complex support and monitoring of multiple organ
dysfunction/failure
OMEGA 1990 (France) 47 therapeutic activities Classified into 3 levels according to frequency
82
TISS-28 1996 79,89 (Europe) 28 in 7 categories; points vary per item (0–8) 46 points = 1 : 1 nursing/shift
23 points = HDU patient (1 : 2 staff-to-patient ratio)
80
NEMS 1997 (Europe) 9 categories with varied points per item (3–12): basic Equivalent scores to TISS-28; lack of discrimination
monitoring, intravenous medication, mechanical limits use in predicting or calculating workload at
ventilation, supplementary ventilatory care, single/ the individual patient level
multiple vasoactive medications, dialysis,
interventions in/outside ICU
CCPDT 1996 (Australia) 7 categories scored 1–4 points: (a) hygiene, mobility, 4 levels of nursing time per shift:
83
wound care; (b) fluid therapy, intake and output, A = ≤10 points = <8 hours
elimination; (c) drugs, nutrition; (d) respiratory care; B = 11–15 points = 8 hours (1 : 1 ratio)
(e) observations, monitoring, emergency treatment; C = 16–21 points = 9–16 hours
(f) mental healthcare, support; (g) admission, D = >22 points = >16 hours (2 : 1 ratio)
discharge, escort
NAS 2003 (Europe/ 23 items (5 with sub-items); varied points per item Measures calculated percentage of nursing time (in 24
81
multinational validation) (1.3–32) (see Table 2.8 for details) hours) on patient-level activities; 100% = 1 nurse per
shift




81
TABLE 2.8 Nursing Activities Scale
Nursing activities score Points
NURSING ACTIVITIES
1. Monitoring and titration
a. Hourly vital signs, regular registration and calculation of fluid balance 4.5
b. Present at bedside and continuous observation or active for ≥2 h in a shift, for reasons of safety, severity, or therapy (e.g. 12.1
non-invasive mechanical ventilation, weaning procedures, restlessness, mental disorientation, prone position, donation
preparation and administration of fluids or medication, assisting specific procedure)
c. Present at bedside and active for 4 h or more in any shift for reasons of safety, severity, or therapy (see 1b) 19.6
2. Laboratory, biomedical and microbiological investigations 4.3
3. Medication, vasoactive drugs excluded 5.6
4. Hygiene procedures
a. Performing hygiene procedures such as dressing of wounds and intravascular catheters, changing linen, washing patient, 4.1
incontinence, vomiting, burns, leaking wounds, complex surgical dressing with irrigation, or special procedures (e.g. barrier
nursing, cross-infection-related, room cleaning after infections, staff hygiene)
b. The performance of hygiene procedures took >2 h in any shift 16.5
c. The performance of hygiene procedures took >4 h in any shift 20.0
5. Care of drains, all (except gastric tube) 1.8
6. Mobilisation and positioning, including procedures such as turning the patient, mobilisation of the patient, moving from bed to a
chair and team lifting (e.g. immobile patient, traction, prone position)
a. Performing procedure(s) up to 3 times per 24 h 5.5
b. Performing procedure(s) more frequently than 3 times per 24 h, or with two nurses 12.4
c. Performing procedure with three or more nurses, any frequency 17.0
7. Support and care of relatives and patient, including procedures such as telephone calls, interviews, counselling; often the support
and care of either relatives or patient allow staff to continue with other nursing activities.
a. Support and care of either relatives or patient requiring full dedication for about 1 h in any shift such as to explain clinical 4.0
condition, dealing with pain and distress, and difficult family circumstances
b. Support and care of either relatives or patient requiring full dedication for 3 h or more in any shift, such as: death, demanding 32.0
circumstances (e.g. large number of relatives, language problems, hostile relatives)

32 S C O P E O F C R I T I C A L C A R E



TABLE 2.8, Continued

Nursing activities score Points
8. Administration and managerial tasks
a. Performing routine tasks such as: processing of clinical data, ordering examinations, professional exchange of information (e.g. 4.2
ward rounds)
b. Performing administration and managerial tasks requiring full dedication for about 2 h in any shift such as: research activities, 23.2
protocols in use, admission and discharge procedures
c. Performing administrative and managerial tasks requiring full dedication for about 4 h or more of the time in any shift such as 30.0
a death and organ donation procedures, coordination with other disciplines
VENTILATORY SUPPORT
9. Respiratory support: any form of mechanical ventilation/assisted ventilation with or without PEEP, spontaneous breathing with or 1.4
without PEEP, with or without endotracheal tube supplementary oxygen by any method
10. Care of artificial airways: endotracheal or tracheostomy cannula 1.8
11. Treatment for improving lung function: thorax physiotherapy, incentive spirometry, inhalation therapy, intratracheal suctioning 4.4
CARDIOVASCULAR SUPPORT
12. Vasoactive medication, disregard type and dose 1.2
13. Intravenous replacement of large fluid losses, fluid administration >83 L/m/day 2.5
14. Left atrium monitoring: pulmonary artery catheter with or without cardiac output 1.7
15. Cardiopulmonary resuscitation after arrest, in past period of 24 h 7.1
RENAL SUPPORT
16. Haemofiltration techniques, dialysis techniques 7.7
17. Quantitative urine output measurement (e.g. by indwelling catheter) 7.0
NEUROLOGICAL SUPPORT
18. Measurement of intracranial pressure 1.6
METABOLIC SUPPORT
19. Treatment of complicated metabolic acidosis/alkalosis 1.3
20. Intravenous hyperalimentation 2.8
21. Enteral feeding through gastric tube or other gastrointestinal route 1.3
SPECIFIC INTERVENTIONS
22. Specific intervention in the ICU: endotracheal intubation, insertion of pacemaker, cardioversion, endoscopies, emergency surgery 2.8
in the previous 24 h, gastric lavage; routine interventions without direct consequences to the clinical condition of the patient
(e.g. X-ray, ECG, echo, dressings, insertion of CVC or arterial catheters) not included
23. Specific interventions outside the ICU; surgery or diagnostics procedures 1.9
TOTAL NURSE ACTIVITIES SCORE



89
a proxy measure of nursing workload in the ICU. One workload, staffing requirements and costing, and to dif-
91
of the primary uses was to aid quantitative comparison ferentiate between ICU and HDU patients. This simpli-
between patients in order to allocate resources, with fied version of 28 items is divided into basic activities
ongoing daily measurements giving an indication of (including monitoring and medications), ventilatory
patients’ progress. The original TISS had a number of support, cardio vascular support, renal support, neuro-
areas for scoring, including patient care and monitoring, logical support, metabolic support and specific
procedures, infusions and medications, and cardiopul- in terventions. The score range is from 1 to 8, with an
monary support. Points assigned to specific interventions ICU-type patient expected to score over 40 points. It
ranged from 1 to 4 for a 24-hour period. A higher score was estimated that a critical care nurse is able to provide
signified a greater therapeutic effort. Several revisions and 46 TISS-28 points per shift, with a score <10 signifying
variants of TISS have been developed in Europe, includ- a ward patient, 10–19 an HDU-type patient, and >20,
79
79
ing TISS-28 and the nine equivalents of nursing man- an HDU/ICU level. Most studies report mean daily
92
93
power (NEMS). 80,90 TISS scores (e.g. 23 [range 14–35], 36 [range 29–49]
94
and 21 [±12] ). Such diversity in scores reflects a
79
TISS-28 was refined to be a more user-friendly instru- range in acuity of patients. Total ICU admission TISS
ment, with similar precision to measure nursing scores are also occasionally reported. 95,96 Importantly,

Resourcing Critical Care 33

the incidence of mortality at hospital discharge was ● provision of training and education to support less
higher in patients discharged from an ICU with a TISS experienced staff
of >20 points than in those with a TISS of <10 points ● development of critical care nursing teams in which
97
(21% versus 4%). TISS was not, however, developed critical care expertise is spread across the teams to
as a predictive tool – rather as a record of the level manage the patient load appropriately, i.e. in satel-
of nursing intervention required. One study noted lite units
that patients with longer ICU stays and worse quality- ● planning for critical care staff sick leave
of-life (QOL) outcomes did not have the increase in ● provision to redeploy pregnant staff
resource consumption that would have been predicted, ● provision of training and education of all staff to
94
as reflected by their TISS. A number of direct-care avoid panic and concern, for example, domestic and
nursing activities were not captured by TISS-28 (e.g. catering staff.
hygiene, activity/movement, information and emo-
tional support), and a revised instrument, the nurs- Stuff
ing activity scale, was developed to address those The ability to manage supplies at times of uncertain
limitations. 81 demand is a key element for examination, as is the
knowledge and understanding of the processes for access-
ing additional equipment such as ventilators and medica-
MANAGEMENT OF PANDEMICS tions from state emergency stockpiles, for example:
● Ensure supplies of appropriate personal protective
Planning for the impact, or potential impact, of a pan- equipment (PPE).
demic is required at the organisational and operational ● Develop plans/policies for the rational use of PPE.
levels, as is the identification of its direct clinical implica- ● Ensure supplies, and access to supplies, of required
tions. This section highlights the areas to be considered medications.
at the organisational level when assessing the response of ● Plan ability to boost ventilator capacity, such as with
an individual facility to such an event. increased use of BiPAP or accessing state emergency
Intensive care beds and their associated resources (equip- stockpile.
ment and staffing) are finite resources and an organisa-
tional response is required to maximise potential ICU Space
capacity. Lessons can be learnt from the global H1N1 This would examine and plan for strategies to function-
pandemic in 2009. The knowledge gained from this expe- ally increase the available critical care bed capacity, as
rience clearly identifies the need to plan for the potential follows:
98
increased demand on critical care services. While it is
beyond the scope of this chapter to cover this subject ● Defer elective surgery.
comprehensively, the aim is to outline briefly the areas ● Explore the ability of local private hospitals to assist
for further examination, touching on the concept of the with service provision for non-deferrable surgical
development of a surge plan. cases.
● Identify alternative clinical areas within the hospital
In earlier experience 98–102 the key role that critical care that may provide additional critical care beds as a
units have to play in an organised response to a pan- satellite unit, such as recovery and coronary care.
demic, particularly an airborne one such as influenza, has ● Triaging access to limited ventilation and/or critical
been demonstrated, as has the reality that critical care care resources. 100,103
units have been more severely affected than other clinical
areas of a hospital. Demand for these services will, at
these times, exceed normal supply. CRITICAL CARE SURGE PLAN
102
The NSW Department of Health provides a template
for the development of a critical care surge plan. This is
DEVELOPMENT OF A SURGE PLAN formatted in a graduated approach and is shown as a
98
Hota et al. describe the preparations for a surge to percentage of current capacity:
service under the three headings ‘Staff, Stuff and Space’. ● pre-surge
The resources required will be examined under these ● minor surge: 5%–10%
headings. ● moderate surge: 11%–20%
● major surge: 21%–50%
Staff ● large scale emergency >50%

The ability to staff a potentially expanded critical care bed The use of such a template, which can be populated
base should examine the following: with locally appropriate definitions and information,
can provide the basis for a comprehensive unit/facility
● staff with critical care skills who do not currently work specific response to the requirement for a graduated
in this area response to a pandemic. Planning for events such as a
● staff from other areas with critical care based skills, pandemic require a coordinated, collaborative approach
such as recovery, anaesthetics, coronary care from all members of the healthcare team, resulting

34 S C O P E O F C R I T I C A L C A R E

in scalable, flexible plans that are underpinned by the
normal management structure and ensure effective lines Case study
of communication.
St Mary MacKillop’s Hospital is a 500-bed, metropolitan, general
teaching public hospital that is planning to build a new 20-bed
SUMMARY intensive care unit. The planners have asked you to act as the
new nurse unit manager for the ICU. Your task is to plan for what
The management of all resources in the critical care is required to make this a functional unit when it is open. The
unit is key to meeting the needs of the patients in a hospital planners inform you that you will ultimately need
safe, timely and cost-effective manner. Many factors influ- 16 ICU beds and 4 HDU beds, but in the first instance they want
ence not only the resources available but also how these you to open half this amount (i.e. 8 ICU and 2 HDU beds).
are allocated. Managers of critical care units are required
to be knowledgeable in the design and equipping of Among other things you must consider the following tasks
units; human resource management, including the and make recommendations to the director of nursing of St
make-up of the nursing workforce; and the fundamentals Mary MacKillop’s Hospital (see Learning activities 1–4). Utilise
of the budget: how it is determined, monitored and information contained in this chapter to inform your work and
managed. recommendations.







Research vignette

Leen T, Williams T, Campbell L, Chamberlain J, Gould A, study period and those admitted during the same time period in
McEntaggart G, Leslie G. Early experience with influenza A H1N1 the previous year. Data sources were identified and included
09 in an Australian intensive care unit. Intensive Critical Care APACHE II and III, and sepsis-related/sequential organ failure
2010; 26(4):207–14. assessment (SOFA), as well as demographic and specific clinical
Abstract data with regard to length of ventilation and length of stay (LOS).
A total of 343 patients were admitted during the period of the
Influenza is a common seasonal viral infection that affects large study. Testing procedures and processes to confirm H1N1 were
numbers of people. In early 2009, many people were admitted to described. The study found that the study population was younger
hospitals in Mexico with severe respiratory failure following an (P = 0.018), with a higher percentage of patients being female
influenza-like illness, subtyped as H1N1. An increased mortality (61%), and that the LOS for the H1N1 population was significantly
rate was observed. By June 2009, H1N1 was upgraded to pandemic longer (P < 0.001) than for the non-H1N1 patients in the same or
status. In June–July, Australian ICUs were experiencing increased the previous year.
activity due to the influenza pandemic. While hospitals imple-
mented plans for the pandemic, the particularly heavy demand to The paper goes on to describe the issues that arose during the
provide critical care facilities to accommodate an influx of people study period and the mechanisms and processes that were devel-
with severe respiratory failure became evident and placed a great oped and implemented to manage them. These issues were similar
burden on provision of these services. This paper describes the to those identified in other studies. There is clear evidence that this
initial experience (June to mid-September) of the pandemic from unit had a surge plan in place, and the discussion identifies how
the nursing perspective in a single Australian ICU. Patients were these experiences will be used to guide planning and clinical prac-
noted to be younger, with a higher proportion of women, two of tices in the future.
whom were pregnant. Two patients had APACHE III comorbidity. Of Descriptive research studies have a clear purpose to allow us to
the 31 patients admitted during this period, three patients died in observe, describe and document naturally occurring situations.
ICU and one patient died in hospital. Aerosol precautions were Their aim is to describe relationships between or among variables
initiated for all patients. The requirement for single room accom- rather than to infer a causal relationship. This research methodo-
modation placed enormous demands for bed management in ICU. logy does not always fit completely into the definition of quali-
Specific infection control procedures were developed to deal with tative or quantitative, but allows us to use elements of each
this new pandemic influenza.
methodology to appropriately and fully describe a situation. This
Critique form of research can afford insights that we may not have previ-
The study initially introduces the H1N1 pandemic and its origins in ously had and also provides us with the basis to identify future
Mexico, describes the unit within which the study was conducted areas of practice development, practice change and research.
and identifies the research methodology as descriptive. The paper
also defines the inclusion and exclusion criteria for the study and This paper clearly described the experiences of this hospital in
data collection. response to the increased demand for critical care services during
the H1N1 pandemic of 2009 and how it responded. The lessons
Descriptive statistics (measures of central tendency such as mean, learnt are not only valuable to the unit in question, but also provide
median and deviance from mean) were appropriately used to valuable information for other units to use in examining their own
compare the two patient populations: those admitted during the response to a similar situation.

Resourcing Critical Care 35



Learning activities
Learning activities 1–4 relate to the case study. staffing and equipment needs, as determined in 1, 2 and 3
1. Calculate the staffing numbers in FTEs that you will require in above. Your task is to compromise where you can to make
the first instance and then when fully functional. Determine staffing and equipment as efficient as possible on a budget
the estimated cost of fully staffing the unit to your satisfaction, that is 80% of that requested in the above questions. Explain
including productive and non-productive FTEs. the reductions you believe you can afford to make in staffing
2. List the standard clinical equipment that you will require for and equipment purchases. How many beds do you think you
each functional bed area, and estimate the cost of this can safely maintain open on this budget?
equipment. 6. Identify a new service that may be required in your healthcare
3. List the one-off clinical equipment items that will be required setting (e.g. the provision of neurosurgery/cardiothoracic
for the unit (i.e. the central monitor, ECG machines, broncho- surgery/hyperbaric chamber) and undertake a cost–benefit
scopes). Determine how many of each you will need in the first analysis of providing this service to your community.
instance and how many you will need when the ICU is fully 7. Identify a piece of equipment or new product that your unit is
functional. Determine the estimated cost of the total equip- considering for purchase and undertake a product evaluation
ment purchase to fully establish the 20-bed unit. to determine its cost-effectiveness.
4. Choose one of the major equipment items that you have iden- 8. Develop a surge plan for your facility to accommodate an
tified in question 3 and write a business case to support its increase in demand for critical care beds. In your plan identify
purchase. all resources that could be redirected to facilitate the imple-
5. Imagine that the hospital wants to open all 20 beds but pro- mentation of this plan.
vides you with only enough funding to cover 80% of your total




FURTHER READING 6. Queensland Health. 2010–2011 Business rules & guidelines, Version 1.2. [Cited
October 2010]. Available from: www.health.qld.gov.au.
Durbin CG. Team model: advocating for the optimal method of care delivery in 7. Queensland Health. Business Rules and Guidelines 2009–2010 (appendices).
the intensive care unit. Crit Care Med 2006; 34(3Suppl): S12–S17. [Cited October 2010]. Available from: www.health.qld.gov.au.
Grover A. Critical care workforce: a policy perspective. Crit Care Med 2006; 8. Department of Human Services, Victoria. Funding for intensive care in
34(3Suppl): S7–11. Victorian public hospitals, prepared March 2010. [Cited October 2010].
Kirchhoff KT, Dahl N. American Association of Critical-Care Nurses’ national Available from: http://www.health.vic.gov.au/__data/assets/pdf_file/0018/
survey of facilities and units providing critical care. Am J Crit Care 2006; 15: 429030/vic_icu_funding.pdf.
13–28. 9. NSW Health. NSW funding guidelines for intensive care services 2002/2003.
Narasimhan M, Eisen LA, Mahoney CD et al. Improving nurse–physician com- September 2002. [Cited October 2010]. Available from: http://www.
munication and satisfaction in the intensive care unit with a daily goals health.nsw.gov.au/pubs/2002/pdf/icsfunding_0203.pdf.
worksheet. Am J Crit Care 2006; 15(2): 217–22. 10. NSW Health. NSW episode funding policy 2008/2009. Sydney: New South
Parker MM. Critical care disaster management. Crit Care Med 2006; 34(3Suppl): Wales Health; 2008.
S52–55. 11. Jackson T, Macarounas-Kirchmann K. Changing patterns of intensive care
Robnett MK. Critical care nursing: workforce issues and potential solutions. Crit unit admission and length of stay in five Victorian hospitals. In: Selby-Smith
Care Med 2006; 34(3Suppl): S25–31. C, ed. Economics and health: 1992. Melbourne: Monash University/NCHPE;
1993. p.149–164.
ONLINE RESOURCES 12. Ettelt S, Nolte E. Funding intensive care – approaches in systems using
diagnosis-related groups. [Cited October 2010]. RAND, California. Available
from: http://www.rand.org/pubs/technical_reports/2010/RAND_TR792.pdf.
Ettelt S, Nolte E. Funding intensive care: approaches in systems using diagnosis- 13. Australian Health Workforce Advisory Committee. The critical care nurse
related groups, http://www.rand.org/pubs/technical_reports/2010/RAND_ workforce in Australia 2002. Sydney: AHWAC; 2002. p.1.
TR792.pdf. 14. Oye RK, Bellamy FE. Patterns of resource consumption in medical intensive
How to write a business case template, http://www.ehow.com/how_4966927_ care. Chest 1991; 99: 685–9.
write-business-case-template.html. 15. Crozier TME, Pilcher DV et al. Long-stay patients in Australian and New
Medical Algorithms Project website, http://www.medal.org/visitor/login.aspx. Zealand intensive care units: demographics and outcomes. Crit Care Resusc
Tasmanian Government business case (small) template and guide, http:// 2007; 9(4): 327–33.
www.egovernment.tas.gov.au/__data/assets/word_doc/0013/15520/pman- 16. Williams T, Ho KM et al. Changes in case-mix and outcomes of critically ill
temp-open-sml-proj-bus-case.doc. patients in an Australian tertiary intensive care unit. Anaesth Intensive Care
University of Queensland ITS business case guide and template, http:// 2010 38(4): 703–9.
www.its.uq.edu.au/docs/Business_Case.doc.
17. Rechner I, Lipman J. The costs of caring for patients in a tertiary referral
Australian intensive care unit. Anaesth Intens Care 2005; 33(4): 477–82.
REFERENCES 18. Paz HL, Garland A, Weinar M et al. Effect of clinical outcomes data on
intensive care unit utilisation by bone marrow transplant patients. Crit Care
1. Galbally B. The planning and organisation of an intensive care unit. Med J Med 1998; 26(1): 66–70.
Aust 1966; 1(15): 622–4. 19. Goldhill DR, Sumner A. Outcome of intensive care patients in a group of
2. Fein IA, Fein SL. Utilisation and allocation of critical care resources. In: British intensive care units. Crit Care Med 1998; 26:1337–45.
Civetta JM, Taylor RW, Kirby RR, eds. Critical care, 3rd edn. Philadelphia: 20. Strosberg MA, Weiner JM, Baker R. Rationing America’s medical care: the Oregon
Lippincott-Raven; 1997. p. 2009–21. plan and beyond. Washington DC: The Brookings Institute Press;
3. Lawson JS, Rotem A, Bates PW. From clinician to manager. Sydney: McGraw- 1992.
Hill; 1996. 21. Williams G. Quality management in intensive care. In: Gullo A, ed. Anaes-
4. Wiles V, Daffurn K. There is a bird in my hand and a bear by the bed – I must thesia, pain, intensive care and emergency medicine. Berlin: Springer-Verlag;
be in ICU. Sydney: ACCCN; 2002. 2003. p. 1239–50.
5. Duckett Stephen J. Casemix funding for acute hospital inpatient services in 22. Gan R, Budgeting. In: Crowther A, ed. Nurse managers: a guide to practice.
Australia. Med J Aust 1998; 169: S17–21. Sydney: Ausmed; 2004.

36 S C O P E O F C R I T I C A L C A R E

23. Weaver DJ, Sorrells-Jones J. The business case as a strategic tool for change. 50. Duffield C, Roche M, O’Brien-Pallas L et al. Glueing it together: nurses, their
JONA 2007; 37(9): 414–19. work environment and patient safety. 2007. [Cited May 2010] Available from:
24. Paley N. Successful business planning – energizing your company’s potential. http://www.health.nsw.gov.au/pubs/2007/pdf/nwr_report.pdf.
Thorogood: London; 2004. 51. Beckman U, Baldwin I, Durie M et al. Problems associated with nursing staff
25. Capezio PJ. Manager’s guide to business planning. McGraw-Hill: Wisconsin; shortage: an analysis of the first 3600 incident reports submitted to the
2010. Australian incident monitoring study (AIMS-ICU). Anaesth Intens Care 1998;
26. Australian Health Infrastructure Alliance (AHIA). Australasian health facility 26: 396–400.
guidelines v. 3.0. 2009. [Cited May 2010]. Available from: http:// 52. Morrison A, Beckmann U, Durie M et al. The effects of nursing staff inexperi-
www.healthfacilityguidelines.com.au/guidelines.htm ence (NSI) on the occurrence of adverse patient experiences in ICUs. Aust
27. College of Intensive Care Medicine. Minimum standards for intensive care units, Crit Care 2001; 14(3): 116–21.
2010. [Cited May 2010]. Available from: http://www.cicm.org.au/cmsfiles/ 53. Martin J, Warne C, Hart G et al. Intensive care resources and activity Australia
IC-1%20Minimum%20Standards%20for%20Intensive%20Care%20 and New Zealand 2005/2006. Melbourne: Australian and New Zealand Inten-
Units.pdf. sive Care Society; 2007.
28. Association of Operating Room Nurses (AORN). Recommended practices 54. Canadian Association of Critical Care Nurses (CACCN). Position statement:
for product selection in perioperative practice settings. AORN J 2004; 79: non-regulated health personnel in critical care areas. 1997. [Cited April 2010].
678–82. Available from: http://www.caccn.ca/en/publications/position_statements/
29. Elliott D, Hollins B. Product evaluation: theoretical and practical consider- ps1997.html.
ations. Aust Crit Care 1995; 8(2):14–19. 55. British Association of Critical Care Nurses (BACCN). Standards for nurse staff-
30. Australian College of Critical Care Nurses (ACCCN). Position statement on ing in critical care. 2009. [Cited April 2010]. Available from: http://
intensive care nursing staffing. 2006. [Cited May 2010]. Available from: http:// www.baccn.org.uk/downloads/BACCN_Staffing_Standards.pdf.
www.acccn.com.au/content/view/34/59. 56. Campolo M, Pugh J, Thompson L et al. Pioneering the 12-hour shift in
31. Australian College of Critical Care Nurses (ACCCN). Position statement on the Australia: implementation and limitations. Aust Crit Care 1998; 11(4):
provision of critical care nursing education. 2006. [Cited May 2010]. Available 112–15.
from: http://www.acccn.com.au/images/stories/downloads/provision_CC_ 57. World Federation of Critical Care Nurses (WFCCN). Declaration of
nursing_edu.pdf. Madrid. Position statement on the provision of critical care nursing edu-
32. New Zealand Nurses Organisation: Critical Care Section (NZNO). Philosophy cation. 2005. [Cited April 2010]. Available from: http://en.wfccn.org/
and standards for nursing practice in critical care, 2nd edn. Wellington: NZNO; pub_education.php
2002. 58. New Zealand Nursing Organisation (NZNO): Critical Care Section. New
33. Clarke T, Mackinnon E, England K et al. A review of intensive care nurse Zealand standards in critical care education, 2nd edn. Wellington: NZNO;
staffing practices overseas: what lessons for Australia? Aust Crit Care 1999; 2000.
12(3): 109–18. 59. Boyle M, Butcher R, Kenney C. Study to validate the outcome goal, compe-
34. Martin J, Warne C, Hart G et al. Intensive care resources and activity Australia tencies and educational objectives for use in intensive care orientation pro-
and New Zealand 2005/2006. Melbourne: Australian and New Zealand Inten- grams. ACC 1998; 11(1): 20–24.
sive Care Society; 2007. 60. Harper J. Preceptors’ perceptions of a competency-based orientation. J Nurs
35. Australian College of Critical Care Nurses (ACCCN). Position statement on the Staff Develop 2002; 18: 198–202.
use of healthcare workers other than division 1 registered nurses in intensive care. 61. ACCCN. Competency standards for specialist critical care nurses, 2nd edn.
Melbourne: ACCCN; 2006. Melbourne: ACCCN; 2002
36. The World Federation of Critical Care Nurses (WFCCN). Declaration 62. Nursing and Midwifery Board of Australia. Nursing and midwifery con-
of Buenos Aires. Position statement on the provision of critical care nursing work- tinu ing professional development registration standard. [Cited July 2010].
force. 2005. [Cited November 2005]. Available from: http://en.wfccn.org/ Available from: http://www.nursingmidwiferyboard.gov.au/Registration-
pub_workforce.php. Standards.aspx.
37. College of Intensive Care Medicine. Recommendations on standards for high 63. Nursing Council of New Zealand. Competence to practise. 2008. [Cited
dependency units seeking accreditation for training in intensive care medicine. April 2010]. Available from: http://www.nursingcouncil.org.nz/index.cfm/
2010. [Cited May 2010]. Available from: http://www.cicm.org.au. 1,86,html/Competence-to-Practise.
38. Adomat R, Hewison A. Assessing patient category/dependence systems for 64. Nursing and Midwifery Council. Meeting the PREP requirements. [Cited April
determining the nurse/patient ratio in ICU and HDU: a review of approaches. 2010]. Available from: http://www.nmc-uk.org/Registration/Staying-on-the-
J Nurs Manag 2004; 12: 299–308. register/Meeting-the-Prep-standards.
39. Clinical Excellence Commission. Between the flags project: the way forward. 65. Valentin A, Capuzzo M, Guidet B et al. Patient safety in intensive care: mul-
2008. [Cited May 2010]. Available from: http://www.cec.health.nsw.gov.au/ tinational sentinel events evaluation (SEE) study. Intensive Care Med 2006;
files/between-the-flags/publications/the-way-forward.pdf. 32: 1591.
40. McGaughey J, Blackwood B, O’Halloran P et al. Realistic evaluation of 66. Valentin A, Capuzzo M, Guidet B et al. Errors in the administration
early warning systems and the acute life-threatening events – recognition of parenteral drugs: multinational prospective study. BMJ 2009; 338:
and treatment training course for early recognition and management of b814.
deteriorating ward-based patients: research protocol. JAN 2010; 66(4): 67. Sexton JB, Thomas EJ, Helmreich RL. Error, stress and team work in medicine
923–32. and aviation. BMJ 2000; 320(7237): 745–9.
41. Tait D. Nursing recognition and response to signs of clinical deterioration. 68. MacFarlane PJM. Queensland health law book, 10th edn. Brisbane: Federation
Nurs Manag 2010; 17(6): 31–5. Press; 2000.
42. Cho SH, Hwang JH, Jaiyong K. Nurse staffing and patient mortality in inten- 69. Knaus WA, Draper EA, Wagner DP et al. An evaluation of outcome from
sive care units. Nurs Research 2008; 57(5): 322–30. intensive care in major medical centers. Ann Intern Med 1986; 104(3):
43. Duffield C, Roche M, Diers D et al. Staffing, skill mix and the model of care. 410–18.
J Clin Nurs 2010; 19: 2242–51. 70. Zimmerman JE, Shortell SM, Rousseau DM et al. Improving intensive care:
44. Numata Y, Schulzer M, van der Wal R et al. Nurse staffing levels and hospital observations based on organisational case studies in nine units – a prospec-
mortality in critical care settings: literature review and meta-analysis. JAN tive, multicenter study. Crit Care Med 1993; 21(10): 1443–51.
2006; 55(4): 435–48. 71. Australian Council for Quality and Safety in Health Care. Open disclosure.
45. Robinson S, Griffiths P, Maben J. Calculating skill mix: implications for [Cited May 2010]. Available from: www.safetyandquality.org.au.
patient outcomes and costs. Nurs Manag 2009; 16(8): 22–3. 72. Iedema R, Mallock N, Sorensen R et al. The National Open Disclosure
46. Flynn M, McKeown M. Nurse staffing levels revisited: a consideration of key Pilot: evaluation of a policy implementation initiative. MJA 2008; 188(7):
issues in nurse staffing levels and skill mix research. J Nurs Manag 2009; 397–400.
17:759–66. 73. Gold M. Is honesty always the best policy? Ethical aspects of truth telling.
47. Needleman J, Buerhaus P, Mattke S et al. Nurse-staffing levels and the quality Intern Med J 2003; 33: 578–80.
of care in hospitals. New Engl J Med 2002; 346: 1715–22. 74. Johnstone M. Clinical risk management and the ethics of open disclosure.
48. Heinz D. Hospital nurse staffing and patient outcomes: a review of current Part I. Benefits and risks to patient safety. Aust Emerg Nurs J 2008; 11(2):
literature. Dimens Crit Care Nurs 2004; 23(1): 44–50. 88–94.
49. Nursing and Midwifery Office. Enrolled nurse – critical care unit project. NSW 75. Madden B, Cockburn T. Bundaberg and beyond: duty to disclose adverse
Health: Sydney; 2009. events to patients. J Law Med 2007; 14(4): 501–27.

Resourcing Critical Care 37

76. Wheatland F. Open disclosure – our right to know. AHC; 2007; 3: 10–11. 91. Garfield M, Jeffrey R, Ridley S. An assessment of the staffing level required
77. Department of Human Services, Victoria. Clinical risk management, root cause for a high-dependency unit. Anaesthesia 2000; 55: 137–43.
analysis. [Cited October 2010]. Available from: www.health.vic.gov.au/ 92. Hamel MB, Davis RB, Teno JM et al. Older age, aggressiveness of care, and
clinrisk. survival for seriously ill, hospitalized adults. SUPPORT Investigators: study
78. Ryan K, MacLochlainn A. Establishment of a peer support program at St to understand prognoses and preferences for outcomes and risks of treat-
Vincent’s Hospital, Sydney. 1995. [Cited October 2010]. Available from: ments. Ann Intern Med 1999; 131: 21–8.
www.clininfo.health.nsw.gov.au/hospolic/stvincents/1995. 93. Jones C, Skirrow P, Griffiths RD et al. Rehabilitation after critical illness: a
79. Miranda DR, de Rijk A, Schaufeli W. Simplified Therapeutic Intervention randomized, controlled trial. Crit Care Med 2003; 31: 2456–61.
Scoring System: the TISS-28 items: results of a multicenter study. Crit Care 94. Rivera-Fernandez R, Sanchez-Cruz JJ, Abizanda-Campos R et al. Quality of
Med 1996; 24: 64–73. life before intensive care unit admission and its influence on resource utiliza-
80. Miranda DR, Moreno R, Iapichino G. Nine equivalents of nursing manpower tion and mortality rate. Crit Care Med 2001; 29: 1701–9.
use score (NEMS). Intens Care Med 1997; 23: 760–65. 95. Backman CG, Walther SM. Use of a personal diary written on the ICU during
81. Miranda DR, Nap R, de Rijk A et al. Nursing activities score. Crit Care Med critical illness. Intens Care Med 2001; 27: 426–9.
2003; 31: 374–82. 96. Moran JL, Peisach AR, Solomon PJ et al. Cost calculation and prediction in
82. Le Gall JR, Lorait P, Mathieu D et al. The patients in management of intensive adult intensive care: a ground-up utilization study. Anaesth Intensive Care
care. In: Miranda DR, Williams A, Loirat P, eds. Guidelines for better use of 2004; 32:787–97.
resources. Dordrecht: Kluwer Academic; 1990; p. 11–53. 97. Smith L, Orts CM, O’Neil I et al. TISS and mortality after discharge from
83. Ferguson L, Harris-Ingall A, Hathaway V. NSW critical care nursing intensive care. Intens Care Med 1999; 25: 61–5.
costing study. Sydney: Sydney Metropolitan Teaching Hospitals Nursing 98. Hota S, Fried E, Burry L et al. Preparing your intensive care unit for the
Consortium; 1996. second wave of H1N1 and future surges. Crit Care Med 2010; 38(4Suppl):
84. Keene AR, Cullen DJ. Therapeutic intervention scoring system: update 1983. e110–19.
Crit Care Med 1983; 11: 1–3. 99. Funk DJ, Siddiqui F, Wiebe K et al. Practical lessons from the first outbreaks:
85. UK Intensive Care Society. Standards for intensive care units. London: UK clinical presentation, obstacles, and management strategies for severe
Intensive Care Society; 1983. pandemic (pH1N1) 2009 influenza pneumonitis. Crit Care Med 2010;
86. Royal College of Nursing. Guidance for nurse staffing in critical care. London: 38(4Suppl): e30–37.
Royal College of Nursing; 2003. 100. NSW Health. Influenza pandemic – providing care: PD2010_28. Sydney: New
87. Donoghue J, Decker V, Mitten-Lewis S et al. Critical care dependency tool: South Wales Health; 2010.
monitoring the changes. Aust Crit Care 2001; 14: 56–63. 101. NSW Health. Influenza guidelines for the intensive care unit GL2010_005.
88. Cullen DJ, Civetta JM, Briggs BA et al. Therapeutic intervention scoring Sydney: New South Wales Health; 2010.
system: a method for quantitative comparison of patient care. Crit Care Med 102. Daugherty E, Branson R, Deveraus A et al. Infection control in mass respira-
1974; 2:57–60. tory failure: preparing to respond to H1N1. Crit Care Med 2010; 38(4Suppl):
89. Reis Miranda D. The Therapeutic Intervention Scoring System: one single e103–9.
tool for the evaluation of workload, the work process and management? 103. Hick JL, Daniel MD, O’Laughlin T. Concept for triage of mechanical ventila-
Intens Care Med 1997; 23: 615–17. tion in an epidemic. Acad Emerg Med 2006; 13(2): 223–9.
90. Rothen HU, Küng V, Ryser DH et al. Validation of ‘nine equivalent of nursing
manpower use score’ on an independent data sample. Intens Care Med 1999;
25: 606–11.

3 Quality and Safety





Wendy Chaboyer
Karena Hewson-Conroy



INTRODUCTION
Learning objectives
Today’s critical care units are both busy and complex,
where nurses, doctors and other health professionals use
After reading this chapter, you should be able to: their knowledge, skills and technology to provide patient
● describe the contribution that evidence-based nursing can care. In fact, this complexity makes errors a common
make to critical care nursing practice. occurrence; one large international study in 205 Intensive
● identify the steps in developing clinical practice guidelines. Care Units (ICU) showed that 39 serious adverse events
● explain the role care bundles and checklists have in occurred per 100 patient days. The Institute of Medicine
1
promoting quality and safety in critical care nursing (IOM) in the USA defines quality of health care as ‘the
practice. degree to which health services for individuals and popu-
● discuss rapid response systems used to respond to lations increase the likelihood of desired health outcomes
deteriorating patients. and are consistent with current professional knowledge’.
2
● describe the use of information and communication Critical care nurses are well known for their skills in
technologies in critical care. patient assessment. In fact, this ongoing surveillance of
● identify techniques used to understand situations that place patient condition means that nurses are ideally posi-
3
patients at risk of adverse events in critical care. tioned to prevent, discover and correct medical errors.
● identify strategies to improve the safety culture in critical Thus, nurses play a key role in improving quality and
care. safety in health care. This chapter provides a review of
quality and safety in critical care. First, an overview of
evidence-based nursing and clinical practice guidelines is
given to provide a foundation to consider quality and
safety. Next, quality and quality monitoring is con-
sidered. Included in this section are the topics of care
bundles, checklists, rapid response systems and informa-
tion and communication technologies. Finally patient
Key words safety, including safety culture is described. In Chapter 2
we addressed risk management, clinical governance and
the role of clinical leaders and managers in delivering
quality improvement critical care services; this information is complementary
patient safety to what will be discussed in Chapter 3.
evidence-based nursing
clinical practice guidelines EVIDENCE-BASED NURSING
health outcomes Evidence-based nursing (EBN) is the ‘Application of
adverse events valid, relevant, research-based information in nurse
information and communication technology decision-making.’ Research evidence, however, is only
4
care bundles one of four considerations in making a clinical decision.
checklists Three other considerations include: (1) knowledge of
safety culture patients’ conditions (i.e. preferences and symptoms); (2)
measurement the nurses’ clinical expertise and judgment; and (3) the
rapid response systems context in which the decision is taking place (i.e. setting,
liaison nurse resources). Figure 3.1 provides a schematic representation
medical emergency team of EBN, using an example of a decision about weaning a
root cause analysis patient from a mechanical ventilator.
failure mode and effects analysis EBN has emerged as a way to improve nursing practice
38 by considering the care that nurses give to patients, and

Quality and Safety 39


Research evidence
• weaning protocols
• systematic reviews




Nurses’ judgement and Clinical decision Patient preferences and
expertise circumstances
• experience • mechanical ventilation • respiratory history (asthma)
weaning method
• assessment skills • anxiety


Available resources
FIGURE 3.1 Schematic represen-
tation of evidence based nursing • type of ventilator
including an example of weaning • staffing
from mechanical ventilation.


Intervention, Comparison, Outcome format, more often
1. Translate a clinical query into a structured question referred to as PICO. The Population reflects the patient
group or clinical scenario of concern. The Intervention is
one option for the particular nursing practice. The Com-
parison is the current practice, or the second option for
2. Locate the best evidence practice. Finally, the Outcome is the effect that the nurse
is hoping to achieve, which should reflect a patient
outcome. Table 3.1 provides three examples of PICO
questions relevant to critical care nursing.
3. Critically appraise the evidence
Locate the Best Evidence
After well-defined, answerable, structured questions have
been developed, nurses can turn to reviewing the litera-
ture to find the answers. First, the evidence has to be
4. Integrate the evidence into practice
located, which involves searching library databases. Some
of the databases generally searched include Ovid CINAHL,
Medline and Cochrane. Articles that relate to the question
then have to be retrieved. These articles may be reports
5. Evaluate clinical performance about primary research (i.e. written by the person con-
ducting the research); systematic reviews of existing
FIGURE 3.2 Steps in the evidence based nursing process. research; or clinical practice guidelines that have been
developed from primary research and systematic reviews.

Critically Appraise the Evidence
whether this care results in the best possible outcomes Once the various sources of evidence have been retrieved,
for patients. It has been viewed as both an attitude and a they are then assessed for their quality and relevance to
process. As an attitude, it is a way of approaching practice the clinical question. In Australia, the National Health
that is critical and questioning. As a process, a number of and Medical Research Council (NHMRC) has described
5
steps in EBN have been described. Figure 3.2 identifies strategies to assess research evidence on the effectiveness
these steps, with more details about each step being pro- of interventions. It provides a useful framework to con-
vided below.
sider research evidence for improving nursing interven-
Translate a Clinical Query into tions, and identifies three questions to ask regarding
potential interventions:
a Structured Question
In situations where nurses have to make clinical deci- 1. Is there a real effect?
2. Is the size of the effect clinically important?
sions, it is important for them to carefully consider the 3. Is the evidence relevant to practice?
issue or problem they are facing as it influences what
research evidence should be used to make decisions. This first question regarding the real effect relates to the
Thus, the first step in the EBN process is translating a strength of the research that has been conducted. The
clinical query into a well-defined, answerable, structured strength of the research has three dimensions: level of
question. A well recognised approach is the Population, evidence, quality of the individual studies, and their

40 S C O P E O F C R I T I C A L C A R E



TABLE 3.1 Examples of clinical questions using the PICO format

Example P – Population I – Intervention C – Comparison O – Outcome
1 Post-operative cardiac surgery Knee-length graduated Thigh-length graduated Prevention of deep vein
patients compression stockings compression stockings thrombosis
2 Mechanically ventilated patients Nurse-led weaning protocols Standard practice Extubation
(doctor-driven)
3 Intubated patients Brushing teeth with a toothbrush Normal saline mouth rinse Ventilator-associated
and toothpaste pneumonia





TABLE 3.2 NHMRC’s level of evidence designation for TABLE 3.3 Types of outcome
5
levels of evidence in the studies of effectiveness
Outcome Definition ICU example
Level of Surrogate Some physical sign or ● Oxygen saturation
evidence Study design measurement ● Vital capacity
I Evidence obtained from a systematic review of all substituted for a
relevant randomised controlled studies clinically meaningful
outcome
II Evidence obtained from at least one properly
designed randomised controlled trial Clinical Outcome defined on the ● Ventilator days
basis of the problem ● Survival
III-1 Evidence obtained from well-designed
pseudorandomised controlled trials (alternative Patient- Outcomes that are ● Functional ability
allocation or some other method) relevant important to the ● Quality of life
patient
III-2 Evidence obtained from comparative studies
(including systematic reviews of such studies),
with concurrent controls and allocation not
randomised, cohort studies, case-control studies, outcomes are those of direct relevance to clinical practice,
or interrupted time series with a control group
and patient-relevant outcomes are those likely to be artic-
III-3 Evidence obtained from comparative studies with ulated as significant by the patient/carer. When assessing
historical controls, two or more single-arm research evidence, the type of outcome used in the
studies, or interrupted time series without a
parallel control group research should be considered. Assessing the evidence
results in an understanding of its quality of evidence for
IV Evidence obtained from case series, either post-test a particular nursing practice.
or pre-test/post-test
Integrate the Evidence into Practice
When good quality evidence for a particular practice is
statistical precision (denoted by P values or confidence identified, it is important to then consider this evidence
intervals). Although there are a number of different alongside nurses’ expertise, patient preferences and avail-
6
evidence hierarchies (e.g. see Jennings & Loan, 2001), able resources. In essence, evidence may suggest that a
5
the framework used by the NHMRC is displayed in particular practice achieves the best patient outcomes, but
Table 3.2. if the nurse does not have the skills needed to implement
the practice, if the resources are not available, if the
The second question focuses on whether meaningful patient either does not want the intervention, or their
improvements to patient care and outcome will result if situation is such that the intervention may not be appro-
the research findings are applied in practice. It also con- priate for them, then this practice should not be imple-
siders how the intervention compares with current prac- mented. However, in many situations the practice will be
tices in terms of patient care and outcomes. applicable to the patient and nurses will have the skills
The third question conveys the notion that potential ben- and the resources to implement the practice. At times,
efits or outcomes of the intervention must be both impor- implementing this new practice may take the form of
tant to the patient, and be able to be replicated in other developing a clinical practice guideline or protocol for a
5
settings. The NHMRC identifies three types of outcome: particular nursing activity. Clinical practice guidelines are
surrogate, clinical, and patient-relevant (which are not described in the next section.
mutually exclusive) (see Table 3.3). Surrogate outcomes
are often used in critical care where measurement of the Evaluate Clinical Performance
actual physiological change (e.g. oxygen-carrying capacity Once a new practice has been implemented, it is impor-
of the blood) is replaced by a more accessible, and equally tant for nurses to assess whether it is having the desired
acceptable, parameter (e.g. oxygen saturation). Clinical effect. At the individual patient level, this often involves

Quality and Safety 41



TABLE 3.4 Steps in developing clinical practice guidelines 9

Step Description
Find the evidence After deciding on what is considered evidence, databases such as CINAHL and Medline must be searched to
find relevant studies and expert opinions.
Evaluate the evidence Relevant studies and expert opinion papers must be critically appraised for their strengths and weaknesses.
This may or may not incorporate a systematic review.
Synthesise the evidence General summary statements about the state of knowledge on a particular topic are developed.
Design the guidelines Written summaries, algorithms and/or summary sheets will be developed that include statements about
appropriate healthcare practices and their rationale.
Appraise the guidelines Validity, reliability, clinical applicability, flexibility and clarity are some criteria that can be used to assess the
guidelines.
Disseminate and implement Specific strategies such as seminars and patient chart reminders must be developed to increase awareness,
the guidelines acceptance and implementation of the guidelines.
Review and reassess the Clinical audits and research may be used to regularly evaluate the impact the guidelines have had on
guidelines patient care and outcomes.




assessing the patient, whereas at the unit level, it may Developing, Implementing and Evaluating
involve either a practice audit or research. Practice audits Clinical Practice Guidelines
often involve reviewing patient charts to determine both
the extent to which the new practice has been imple- A number of steps are undertaken when developing clini-
mented and its outcome on the patient. Research may cal practice guidelines. Table 3.4 provides an overview of
seek to understand similar things, but generally takes a these steps, which has been adapted from Miller and
9
more formal approach, addressing issues such as appro- Kearney’s work.
priate study designs, ethics approvals, etc. While research, systematic review and expert opinion
form the foundation for CPGs, the quality of evidence
CLINICAL PRACTICE GUIDELINES must be assessed and overall summaries of the knowl-
The development and use of clinical practice guidelines edge to date are essential. These summaries are then used
(CPGs) is one strategy to implement EBN. CPGs are state- to develop the guidelines, which generally include a
ments about appropriate health care for specific clinical series of statements about the care to be provided and a
circumstances that assist practitioners in their day-to-day rationale for this care.
practice. They are systematically developed to assist Once the guidelines are developed, a group of experts and
7
clinicians, consumers and policy makers in healthcare users should assess the guidelines for accuracy, clinical
decisions and provide critical summaries of available evi- utility and comprehension. Recently, international experts
dence on a particular topic. Other terms that are often developed a 23-item appraisal instrument, termed the
8
used synonymously with CPGs include protocols and Appraisal of Guidelines for Research and Evaluation
algorithms. (AGREE), that assesses five domains: (1) scope and
purpose of the CPG (3 items); (2) stakeholder involve-
There are a number of benefits of using CPGs. They are
seen to be central to quality patient care because, in ment in CPG development (4 items); (3) rigour of devel-
9
essence, they standardise care. They can guide decisions opment (7 items); (4) clarity and presentation (4 items);
and can be used to both justify and legitimise activities and (4) applicability (5 items). Instruments such as
9
and practices. However, limitations have also been iden- AGREE can be used to assess the quality of CPG.
tified. Poorly developed guidelines may not improve care Based on the assessment of the CPG, revisions may be
9
and may actually result in substandard care . In the criti- required. Next, strategies for disseminating and imple-
cal care area, the Intensive Care Coordination and Moni- menting the guidelines should be developed. Impor-
toring Unit of New South Wales Department of Health tantly, simply publishing and circulating CPGs will have
has led the development of CPGs associated with six a limited impact on clinical practice, so specific activities
common nursing interventions: (1) Eye care; (2) Oral must be undertaken to promote CPG adherence. The fol-
care; (3) Suctioning a tracheal tube; (4) Endotracheal lowing seven strategies have been shown to be moder-
tube stabilisation; (5) Central line care; and (6) Arterial ately effective in promoting guideline adherence: (1)
10
line care. Clinical audits are often used to establish the interactive small group sessions; (2) educational outreach
need to develop new protocols at the local unit level. visits; (3) reminders; (4) computerised decision support;
Clinical audits generally involve chart reviews, but may (5) introduction of computers in practice; (6) mass media
7
also use direct observation or surveys of practice. Clinical campaigns; and (7) combined interventions. Finally, a
audits often establish variation in practice without ade- process for regularly evaluating and updating the guide-
quate justification. lines must be developed, which may involve quality

42 S C O P E O F C R I T I C A L C A R E

improvement activities or clinical research. In summary, About 18,000 hospital deaths per year are associated with
13
by developing, using and evaluating clinical practice AEs and generally occur as a result of system errors. Half
guidelines, nurses may improve patient care and out- the AEs were deemed preventable with such strategies as
comes. Additionally, use of CPGs should ensure that improved protocols, better-quality monitoring, enhanced
nursing practice is based on the best available evidence. training and opportunities to consult with specialists or
17
peers on clinical decisions. Studies have identified spe-
QUALITY AND SAFETY MONITORING cific contributing factors for adverse events related to
18
patient airway and intra-hospital transports. 19
This section discusses unit-level measures used to evalu-
ate the quality and safety of care for critically ill patients. A number of methods for reporting AE such as direct
Quality and safety in healthcare is commonly described observation chart audit and self or facilitated reporting
11
in terms of Donabedian’s approach with three major can be used; each has its strengths and limitations.
domains: Trained observers report more unintended events but this
method is expensive, labour intensive and vulnerable to
20
1. Patient outcomes – the results of care in terms of the Hawthorne effect. Both chart audits and incident
recovery, restoration of function and/or survival reporting only reflect what is charted or reported, but
(e.g. mortality, health-related quality of life). even when chart audit, incident reporting, general prac-
2. Process – the practices involved in the delivery of titioner reporting and external sources, such as coronial
care (e.g. pressure ulcer prevention strategies). review, are used together, some adverse events will be
3. Structure – the way the healthcare setting and/or missed. Importantly, self or facilitated reporting, such as
21
system is organised to deliver care (e.g. staffing, the Australian Incident Monitoring Study (AIMS) 22,23 are
beds, equipment). routinely used surveillance methods in many countries.
More recently, a fourth domain of culture or context has Medication administration is the most common inter-
been suggested specifically for patient safety models to vention in health care, but the medication management
12
evaluate the context in which care is delivered. The process in the acute hospital setting is complex, and
contemporary model for healthcare improvement recog- creates risk for patients. As a result, medication-related
24
nises that the resources (structure) and activities carried events are the commonest AE for hospitalised patients.
out (processes) must be addressed within a given context Adverse drug events (ADEs) are common in Australian
(culture) to improve the quality of care (outcome). The hospitals, with preventable, high-impact events involving
overall aim of quality improvement (QI) is to provide anticoagulants, anti-inflammatories and cardiovascular
safe, effective, patient-centred, timely, efficient and equi- drugs (over 50% of ADEs), as well as antineoplastics,
13
table health care. QI activities identify and address gaps opioids, steroids and antibiotics (commonly used in criti-
between knowledge and practice. Importantly, these cal care units). Events are clinically significant in 20%
17
17
activities need to reflect the most recent and robust clini- of cases. A number of strategies have been instituted in
cal evidence to improve patient care and reduce harm. Australia under the auspices of the National Medicines
The most common approach used for rapid improvement Policy, including the quality use of medicines (QUM)
14
in healthcare is the plan–do–study–act (PDSA) method framework. There, however, remains a lack of consensus
where four essential steps are carried out in a continuous on how to measure medication safety – either by error
25
fashion to ensure processes are continually improved: or adverse event – where:
1. Plan – identify a goal, specify aims and objectives ● error is a failure in clinical management, resulting in
to improving an area of clinical practice, and potential harm to the patient
how that might be achieved (i.e. how to test the ● adverse events relate to actual patient harm (injury). 17
intervention).
2. Do – implement the plan of action, collect relevant The actual incidence of both measures is higher than
17,26
information that will inform whether the interven- what is reported. Fortunately, most healthcare errors
tion was successful and in what way, taking note do not result in patient harm because of safety-net pro-
24
of problems and unexpected observations that cesses. Despite this, it has been estimated that one
arise. potentially serious intravenous drug error occurs every
27
3. Study – the results of the intervention, particularly day in a 400-bed hospital. Approximately 5% of medi-
its impact on practice improvement, noting any cation errors relate to infusion pumps. These pumps
strengths and limitations of the intervention. are used to administer high-impact medications, such as
28
4. Act – determine whether the intervention should inotropes, heparin or antineoplastics. It is therefore
be adopted, abandoned or adapted for further important to evaluate interventions that can reduce the
rapid cycle testing recommencing at the Plan phase. incidence and impact of adverse intravenous drug events,
particularly in critical care settings. 29,30 Recent evidence
A variety of specific activities have been used in the ICU suggests that nurses who are interrupted whilst admini-
setting to translate findings from the literature to improve stering medications may have an increased risk of making
15
31
clinical practice. Quality monitoring includes measure- medication errors, prompting calls for all healthcare
ment of, and response to, the incidence and patterns of workers to make concerted efforts to reduce interruptions
adverse events (AEs). Adverse events occur in up to 17% to clinical tasks. Other activities examining quality
32
13
of all hospital admissions, and cost the Australian of care include the analysis of incident reports such as
16
healthcare system an estimated $2 billion per year. the Australian Incident Monitoring Study (AIMS), 22,23

Quality and Safety 43

17
Quality in Australian Health Care Study (QAHCS) and during patient assessment is the ‘FASTHUG’ which stands
the Australian Council on Healthcare Standards (ACHS) for Feeding, Analgesia, Sedation, Thromboembolism pro-
33
indicators. Current ACHS indicators for intensive care phylaxis, Head-of-bed elevation, stress ulcer prevention
39
include: and Glucose management. Along with care bundles and
checklists (detailed below) these tools facilitate stan-
● inability to admit a patient to the ICU due to inade-
quate resources dardised care and improve communication between
38
● elective surgery deferred or cancelled due to lack of clinicians.
ICU/HDU bed
● patients transferred to another facility due to unavail- CARE BUNDLES
ability of an ICU bed An evolving QI approach to the optimal use of best prac-
● delays on discharging patients from the ICU of more tice guidelines at the bedside is the development of ‘care
than 12 hours bundles’. A care bundle is a set of evidence-based inter-
● patients discharged from the ICU after hours (i.e. ventions or processes of care, applied to selected patients.
between 6pm and 6am) A number of bundles have been developed for critical
● recognising and responding to clinical deterioration care by the Institute for Healthcare Improvement (IHI) in
within 72 hours of being discharged from ICU the USA (see Table 3.6).
● patients being treated appropriately for VTE prophy-
laxis within 24 hours of admission to the ICU Table 3.7 outlines studies examining the process of
● ICU central line-associated bacteraemia rates care delivery in critical care units, including those
● use of patient assessment systems (participation in where care bundles were implemented and evaluated.
national databases and surveys). 33 Increased bundle compliance was associated with
decreased ICU length of stay (LOS), reduced ventilator
Similar activities are evident internationally, where con- days and increased ICU patient throughput, and
40
cepts of ‘safety science’ (error reduction and recovery) are decreased rates of ventilator-associated pneumonia.
41
being applied to critical care practice. 29,34-36 Process indi- Other quality improvement studies targeted similar pro-
cators of quality care have been developed, including care cesses of care without taking the bundled approach. A
related to the prevention of ventilator-associated pneu- range of measures demonstrated improved outcomes:
monia (VAP) and central venous catheter management.
Table 3.5 outlines process indicators with good clinical ● decreased VAP, 42,43 catheter-related bloodstream infec-
evidence and/or strong recommendations for use by tion (CR-BSI) rates and LOS 43
professional bodies, such as the Agency for Healthcare ● increased days between CR-BSIs 44
Research and Quality (AHRQ) in the USA. ● decreased hospital mortality as the number of process
interventions increased 45
A range of clinical support tools have been developed and ● reduction in severity-adjusted total hospital costs
are used to measure compliance with these best practice related to improvements in process measures of care,
clinical standards. Daily goals forms, for example, have including glucose control, use of enteral feeding and
been used to aid communication between clinicians appropriate sedation. 46
during and after multidisciplinary ward rounds and
ensure that all staff are aware of what care the patient Although studies revealed improvements in both pro-
should be receiving and what the clinical plan is. 37,38 A cesses and outcomes, variation in levels of compliance
popular mnemonic developed for use by ICU clinicians with process measures were also reported (see Table 3.7
47
for detail). One study revealed the more unwell the
patient was, the less likely they were to have received
practices they were eligible for.
TABLE 3.5 Evidence based process indicators
CHECKLISTS
Process Process indicator
Checklists have the potential to prevent omissions in care
1. Central venous Maximum sterile barriers by serving as reminders to healthcare providers for the
catheter Real-time ultrasound guidance during delivery of appropriate quality care for every patient,
management insertion every time, in complex clinical environments. A checklist
Antibiotic-impregnated catheter
typically contains a list of action items or criteria arranged
2. Prevention of Elevated head of bed in a systematic way, allowing the person completing it to
ventilator- Continuous aspiration of subglottic record the presence or absence of individual items to
associated secretions 48
pneumonia Stress ulcer prophylaxis ascertain that all are considered or completed.
3. Reducing Low tidal volumes for acute respiratory In critical care settings, checklists have been used to facili-
mechanical distress syndrome tate staff training, detect errors, check compliance with
ventilation Weaning protocols safety standards and evidence-based processes of care
Sedation protocols
Appropriate use of analgesia and sedation (such as those outlined previously), increase knowledge
of patient-centred goals and prompt clinicians to review
4. Pressure ulcer Use of pressure-relieving materials certain practices on morning rounds in the ICU. Findings
prevention
from studies noted that checklists:

44 S C O P E O F C R I T I C A L C A R E



TABLE 3.6 Institute for Healthcare improvement care bundles

Bundle name Aim Bundle components
Central line Prevent central-line ● hand hygiene
associated bacteraemia ● maximal barrier precautions upon insertion
● chlorhexidine skin antisepsis
● optimal catheter site selection with avoidance of the femoral vein for central
venous access in adult patients
● daily review of line necessity with prompt removal of unnecessary lines
Ventilator care Prevent ventilator- ● elevating the head of the patient’s bed to 30–45 degrees
associated pneumonia ● daily ‘sedation vacations’ or gradually lightening sedative use each day
● daily assessment of the patient’s readiness to extubate or wean from the ventilator
● delivering both peptic ulcer disease and deep vein thrombosis prophylaxis
Sepsis resuscitation Reduce mortality due to ● serum lactate measured
severe sepsis ● blood cultures obtained prior to antibiotic administration
● improve time to broad-spectrum antibiotics
● treat hypotension and/or elevated lactate with fluids
● apply vasopressors for ongoing hypotension
● maintain adequate central venous pressure
● maintain adequate central venous oxygen saturation
Sepsis management Reduce mortality due to ● administer low-dose steroids by a standard policy
severe sepsis ● administer Drotrecogin Alfa (Activated) by a standard policy
● maintain adequate glycaemic control
● prevent excessive inspiratory plateau pressures



● assisted in improving the understanding patient ‘a consolidated and summarized record of an individual’s
therapy goals 49 health information for consumers to access and for use
● improved compliance with safety standards 50 as a mechanism for improving care coordination between
● detected patient safety errors and omissions in care provider teams’.
58 (p.13)
51
care 52,53
● improved compliance with evidence-based In combination with these initiatives, information and
care 44,50,54,55 communications technologies (ICT) are also expanding
60
● proved useful in preparing for a procedure 56 into clinical practice. Critical care in particular is at
● were not time consuming 52-53 or labour intensive 52 the forefront of these developments, with bedside clinical
● when developed in conjunction with clinicians, information systems, order-entry strategies, decision
produce a valid and reliable tool that is consistently support, handheld technologies and telehealth initiatives
used 52 continuing to evolve and influence practice. This section
● enabled collection of real-time process measures to examines the current and future impact that these tech-
assist in the immediate identification of anomalies. 44 nologies will have on patient care and safety, and on clini-
cian workflows and practices, as clinical information fully
Three studies suggested that checklists also contributed assimilates with evidence-based practice and clinical deci-
to improved outcomes: (1) reduced LOS, ventilator days, sion support systems.
49
unit mortality; (2) reduced catheter-related bloodstream
44
infections; and (3) reduced mean monthly rates of
54
VAP. However, the lack of methodological rigour in Clinical Information Systems
these studies prevents inferring causal links between A clinical information system (CIS) enables improved
checklist use and improved outcomes. 57 data collection, storage, retrieval and reporting of patient-
based information, and can facilitate unit-based out-
comes research and quality improvement activities.
61
INFORMATION AND COMMUNICATION Computerisation of monitoring and therapeutic activities
TECHNOLOGIES for critically ill patients began in the 1960s, and has now
Health departments continue to develop systems and evolved to encompass all aspects of patient care such as
cardiorespiratory monitoring, mechanical ventilation,
processes that will result in a complete electronic medical fluid and medication delivery, imaging and results of
record. In Australia, a national e-health strategy has been diagnostic testing. 62,63 Patient-based bedside CIS offers
58
established, with the National E-Health Transition increasingly sophisticated functionality and device inter-
Authority (NEHTA), a company established by the faces, enabling real-time data capture, trending and
64
Australian, State and Territory governments, assigned reporting, and linkage to relational databases. 65,66
62
responsibility for establishing the foundations (including
the development of standards) for e-health across the The introduction of intravenous ‘smart pump’ technology
59
Australian health sector. The ultimate goal is an indi- is one application aimed at reducing adverse drug events
vidual electronic health record system designed to provide and improving patient care by supporting evidence-based

Quality and Safety 45






(19.3/1000 ventilator days) and Intervention year 1 No difference in VAP rate between historical control year (16.6/1000 vent days), P = 0.62. Significant reduction after Intervention year 2 (7.3/1000 Median VAP rate significantly lower during Year 2 compared with control year (Z = 2.2, P = 0.028) and year 1 Reduction in VAP rates (P = 0.0004) using time series Patient severity of illness significantly higher in post- FASTHUG group compare
















Findings ● ● vent days), P < 0.01 ● (Z = 2.04, P = 0.028). ● analysis ● (P = 0.001) ● ● practices. ● ● others (P = 0.048). ● ● control 41.9% (30–87%). ● received all 4 measures ● ● interventions increased ●





Historical control (1 year pre-intervention) and year 1 combined were compared to extended post-FASTHUG period Year 1 – procedural interventions included oral care, early extubation, management of respiratory equipment, hand-washing & Year 2- FASTHUG used on twice daily Compliance with care processes not measured No randomisation, no causal links between Multiple regression analysis tested the association between compliance (%) and sever








Method / Critique ● ● maximal sterile precautions ● patient rounds ● ● process and outcomes ● trauma vs medical). ● actual delivery ● among associations found ● ● specific comorbidities) ● ● ● regression model




Studies describing process of care delivery in critical care units 57







n/cohort 1315 (over 2 yrs pre-intervention); 1653 (over 3 yrs post-intervention) 100 randomly selected patients admitted over 1 yr 1463 cases, mech. vent >96 hours
Sample






Setting 10-bed surgical ICU 20-bed tertiary academic medical-surgical- trauma ICU 38 academic medical centres – 114 ICUs of 15 types (65% medical, surgical, cardiac, cardiothoracic)


Before/after study using historical control in a single-centre Retrospective observational study reviewing both print and electronic medical records Point prevalence; Retrospective chart review


Design



TABLE 3.7 Study Papadimos et al. 2008. (USA) 42 Ilan et al. 2007. (Canada) 47 Keroack et al. 2006. (USA) 45

46 S C O P E O F C R I T I C A L C A R E








98.6%; DVT prophylaxis greatest variability in Adherence to ventilator bundle increased from 73% to VAP rate reduced 54% from 11.4/1000 ventilator days to 5.3/1000 resulting in 22.5 fewer VAP occurrences Rate of CR-BSIs reduced 78% from 12.8 to 2.88 Mean LOS reduced 18% from 3.59 to 4.4 days Annual cost savings = $97,700–$267,700 for reduction in VAP; $220,000–$1,309,000 for reduction in CR-BSIs; $726,600 for reduced mean length of stay 57% of team














Findings ● implementation ● ● ● ● ● ● ● ● ventilator bundle ● 3.8/1000. ●















Method / Critique ● Multi-faceted intervention included clinician engagement, daily rounds & pt goals forms, data feedback, range of communication strategies & rewards using rapid-cycle approach ● ‘HOTSPUD’ mnemonic reminder: HOB>30 ° , oral care, turning pt, sedation vacation, peptic ulcer and DVT prophylaxis ● Impact of individual components of multi-faceted intervention not reported ● Compliance with individual care components not detaile













n/cohort Not stated Not stated Not stated
Sample






Setting 8-bed medical ICU over 12 months 35 ICUs 14-bed adult medical ICU





Continued Design Prospective, before-after Before–after Before-after using real time process measurement




TABLE 3.7, Study Hatler et al. 2006. (USA) 43 Resar et al. 2005. (USA) 41 Wall et al. 2005. (USA) 44

Quality and Safety 47



stop increased (29 to 63%). PUD prophylaxis 100% at both
Compliance with care bundle: DVT prophylaxis decreased
Mean ventilator days reduced from 10.8 days to 6.1 days
(81 to 71%), HOB >30 ° increased (71 to 83%) & sedation
Mean ICU LOS reduced from 13.75 days to 8.36 days






ventilated pts increased 39.5% Unit pt throughput increased 30% and no. of invasively Performance varied widely among & within 13 ICUs Median (ranges): effective assessment of pain 84% (30–98%); appropriate sedation 64% (2–100%); head of bed elevation 67% (42–99%); appropriate SUP 89% (71–98%); appropriate DVT prophylaxis 87% (48–98%) Sig improvement in glucose control (mean of all glucose measurement reduced from 9.9 ± 4.4 to







Findings ● points in time ● (P <0.05) ● ● ● ● ● ●







Evaluated impact of a ventilator care bundle (PUD & DVT prophylaxis, sedation stop, HOB > 30 ° ) on outcomes Audit data by chart review; compliance (pre- and post-implementation of care Measure outcomes over 2 yr study period Only limited improvement in compliance, other factors could have influenced changes Compliance of process measures ‘Appropriateness’ of SUP and DVT prophylaxis not clearly defined or explicitly evaluated Reported resu






Method / Critique ● ● bundle, 7 months apart) ● ● Methods not detailed ● in outcomes ● ● No outcome measures ● ● ● ● ● No randomisation ● analysis not described ● Abbreviations: ICU = intensive care unit; HDU = high dependency unit; QI = quality improvement; CQI = continuous quality improvement; no. = number; b/w = between; yr = year; pts = patients; grp = group; hosp = hospital; sig = significant; mx = management; mech








Baseline audit n = 21 (pt obs.); Post- implementation audit n = 24 Pt outcomes & unit activity: Pre-test: 286; Post-test: 372 512–602 per yr)



n/cohort Not stated 2,764 (range: over 5 yrs
Sample






Setting 6-bed general ICU/ HDU 13 adult medical & surgical ICUs in urban teaching & community hospitals. 12-bed tertiary shock/trauma/ respiratory ICU






Design Retrospective Prospective, cross- sectional, observational Before/after quasi- experimental with historical controls stay; SPC = statistical process control






Study Crunden et al. 2005. (UK) 40 Pronovost et al. 2003. (USA) 52 Clemmer et al. 1999. (USA) 46

48 S C O P E O F C R I T I C A L C A R E

67
guidelines for medication management. The operator- practice guidelines, real-time clinical alerts, and online
error prevention software is based on a device-based patient historical information via a complete electronic
drug library with institution-established concentrations/ medical record. 78
dosage limits incorporated in the function of the pump.
Resulting software functions include clinician alerts (for Computerised Order Entry and
28
keystroke errors) and transaction log data (post-incident Decision Support
68
analysis). Medication errors and adverse drug events can
be detected by this software, but further technological Computerised physician (or provider) order entry (CPOE)
and nursing behavioural factors must be addressed before is viewed as an important innovation in reducing medical
25
a measurable impact on serious adverse drug errors can errors, through minimising transcribing errors, trigger-
be achieved. 69 ing alerts for adverse drug interactions and facilitating the
adoption of evidence-based clinical guidelines. 70,73,79,80
The proportion of ICUs in Australia and New Zealand
using a CIS is not known, while the estimate for units Computerised order entry is used for medication and
using electronic charting in North America is 10–15%. 64,70 intravenous fluid prescribing, diagnostic test ordering
Early generation systems held promise of improved and results management, and mechanical ventilation
79,81
efficiencies but did not demonstrate actual decreases or other treatment orders. Implementation of CPOE
in nursing workload or activity patterns, including in and related clinical decision support systems (CDSS)
71
one Australian site. Current third-generation systems have demonstrated significant reductions in medication
79
82-84
(Windows NT operating system [or equivalent] with errors and redundant or unnecessary order requests, 85-86
relational databases and enhanced graphic displays and and improved compliance with practice guidelines.
63
user interfaces) have reduced documentation time (52 Clinical decision support systems interface with hospital
minutes per 8-hour shift) and increased the proportion databases to retrieve patient-specific and other relevant
87
72
of time on direct care activities. Despite these positive clinical data and to generate recommended actions.
findings, it is noted that a CIS would not enable a reduc- Importantly, clinical decision making at the bedside can
tion in nursing staff; on the contrary, at least a half-time be enhanced by providing clinicians with a readily avail-
72
nursing position is required to administer the system. able tool that incorporates relevant clinical information
88
An Australian study demonstrated significant reductions and evidence-based medicine. Clinician alerts (e.g.
in medication and intravenous fluid errors and the inci- allergies or interaction effects) or prompts (e.g. to check
dence of pressure areas, and improved variance between coagulation when prescribing warfarin) can be generated.
ventilator orders and settings, after implementation of a A number of studies have demonstrated improved
73
CIS. A sample of nursing staff perceived that the CIS delivery of patient care after the introduction of such
89-91
also increased time on patient care and decreased docu- reminders. As with CIS implementation, examination
81
mentation time, while staffing recruitment and retention of clinician workflow and care delivery patterns and
73
rates improved. Findings that critical care nurses are detailed planning is required for successful implementa-
92
accepting of new technologies were previously noted. 74 tion of a CPOE process. In particular, order decryption,
prioritisation and translation steps within the medication
Other issues also need consideration. Accuracy of data or treatment order process require review to minimise
92
(correctness and completeness of the data set) from both potential errors. Additional developments involving
manual and automated inputs to the information system wireless communication, personal digital assistants and
requires evaluation. While automated entry eliminates closed-loop delivery systems will improve the efficiency,
75
transcription errors from other data sources, the use of effectiveness and adoption of this innovation in clinical
79
‘carry-over’ data to new fields, sampling frequency, and practice. Closed-loop delivery adjusts drug or fluid
clinician acceptance of monitor-generated data can erro- delivery based on active feedback from the target param-
neously affect data accuracy (e.g. damped pulmonary eter (e.g. inotropic dosages adjusted to a range for mean
artery waveform not checked, with erroneously low read- arterial pressure).
61
ings documented). In addition to errors related to enter-
ing and retrieving information, errors can also arise if Handheld Technologies
systems are not designed to enhance communication
between healthcare workers and facilitate coordination of Wireless applications enable both clinical access and por-
76
work processes. Further, ‘clinical alert’ functions can tability and mobility within a critical care environment
lack the specificity for detecting clinically important at the point of care. Clinical uses for personal digital
70
events and may compromise patient safety when used assistant (PDA) and Smartphone technologies continue
93
excessively in clinical settings with one study demonstrat- to evolve at a rapid pace. These handheld computers
ing 49–96% of drug safety alerts were overridden by use operating systems and pen-like styluses that enable
clinicians. 77 touch-screen functionality, handwriting recognition, and
synchronisation with other hospital-based computer
To tackle these and other limitations, future systems will systems. An increasing array of clinical applications and
provide wireless capabilities, remote access, ‘smart’ alerts, content are available for downloading to PDAs, including
handwriting recognition, clinician-configured forms, drug reference information (e.g. MIMS on PDA), clinical
flowcharts and reports using standardised data structures guidelines, medical calculators and internet-based
and terminology. This level of functionality will enable literature searches. 93-95 PDA use has been reported as a
decision support with online evidence-based clinical helpful nursing education tool, 96,97 with nursing students

Quality and Safety 49

reporting specific benefits of PDA use such as having effective elements of this technology in critical care
access to readily available data, validation of thinking settings. 102,108
97
processes and facilitation of care plan re-evaluation. In In addition to remote patient assessment and manage-
critical care, PDAs have been used to document clinical ment, telecommunications have been used to deliver
activities, such as logging critical care procedures, which continuing education to rural healthcare professionals
was demonstrated as feasible and useful, although adop- for many years via audio, video and computer. More
109
98
tion and user acceptance was not uniform. They have recently, distance education has been delivered via web-
also been used to deliver point-of-care decision support based courses accessed over the internet. For example,
110
84
99
to improve antibiotic selection and prescribing, and a web-based educational tool was used to provide infor-
an interactive weaning protocol that assisted care provid- mation about the classification of pressure ulcers and the
ers wean patients from mechanical ventilation more effi- differentiation between pressure ulcers and moisture
ciently when compared with the use of a paper-based lesions to both student and qualified nurses. The poten-
111
weaning protocol. 100
tial use of web logs or ‘blogs’, online communities and
112
110
The benefits of this mobile computing also create con- virtual preceptorships in nursing education has also
cerns, particularly regarding confidentiality of patient been discussed. Continuing professional development
information. Health services therefore need policies for (CPD) opportunities are also provided on-line, for
managing handheld devices, including password protec- example AusmedOnline contains a range of resources
tion, data encryption, authenticated synchronisation and and learning activities that count towards CPD for regis-
physical security. In particular, wireless applications tration requirements. However, more work is required to
95
require appropriate standards for data security (e.g. determine how successful these technological advances
78
wireless-fidelity protected access 2 [WPA2] compliance). are on educational outcomes. 113
As these issues are addressed, these technologies will
form an integral component of routine clinical practice PATIENT SAFETY
in critical care.
114
The signing of the Declaration of Vienna in 2009
(Appendix A4) committed critical care organisations
Telehealth Initiatives around the world, including the World Federation of
114
Remote critical care management (eICU) using Critical Care Nurses, to patient safety. Patient safety is
telemedicine/telehealth technologies is expanding as the viewed as a crucial component of quality. Over the
115
necessary high bandwidths for transmitting large amounts years, numerous definitions of patient safety have emerged
of data and digital imagery become available between in the literature. The Institute Of Medicine described it
116
partner units or hospitals. Videoconferencing functions as the prevention of harm, however, more recently, the
enable direct visualisation and communication of patients European Agency, Safety Improvement for Patients in
117
and on-site staff with the ‘virtual’ critical care clinician Europe, asserted it was about identifying, analysing and
or team. Review of real-time physiological data, patient minimising patient risk. This latter description is appeal-
flowcharts and other documents (e.g. electrocardiograms, ing as it leads us to consider the degree of risk situations
laboratory results) or images (e.g. radiographs) provide a pose for patient harm and targeting those that are either
comprehensive data set for patient assessment and high risk or frequent in occurrence.
management. 101
Three techniques used to understand patient risk are ana-
This technology-enabled remote care initiative is of par- lysing reports of adverse events, root cause analyses and
ticular value for critical care units where no or limited failure mode and effect analysis. Recent research on
on-site intensivist resources are available. Despite various adverse events in critical care has helped to both better
102
methodological limitations, several studies using understand patient risks and target improvement activi-
‘before and after’ comparisons have indicated improved ties. For example, medications, indwelling lines and
outcomes such as decreases in severity-adjusted hospital equipment failure were the three most frequent types of
mortality, incidence of ICU complications, ICU length adverse events in a study of 205 Intensive Care Units
1
of stay, and ICU costs. 101,103,104 One study demonstrated world-wide. Focusing on analysing the narratives written
improved outcomes for neurological ICU patients about adverse events is viewed as an important way to
through the use of a robotic tele-ICU system that made learn from errors. Root cause analyses is a structured
104
rounds in response to nurse paging. More recent process generally used to analyse catastrophic or sentinel
studies, however, have not found improvement in patient events. 118,119 Learning from both incident reporting such
outcomes as a result of telemedicine technology, 105-107 as AIMS and root cause analyses is based on the premise
highlighting the complex nature of these initiatives that the information they contain is of sufficient quality
and the difficulties evaluating them. One local study to allow accurate analysis, interpretation and detection of
instead observed improvements in patient management the root causes of problems, and even more importantly,
(i.e. increased discharges and decreased transfers) for the formulation and implementation of corrective actions.
moderate trauma patients upon implementation of a Failure mode and effect analysis identifies potential
virtual critical care unit that linked a district hospital failures and their effects, calculating their risk and
120
ED with a metropolitan tertiary hospital ED. Further prioritising potential failure modes based on risk. In
studies that include detailed descriptions of system addition to examining patient risk, another strategy has
implementation are required in determining the most focused on understanding the safety culture of a unit or

50 S C O P E O F C R I T I C A L C A R E

organisation, with subsequent activities aimed at improv- these skills can be learned. For example, the Anaesthetists’
ing components of this culture. Non-Technical Skills (ANTS) is a training program
developed in Scotland, that focuses on task management,
SAFETY CULTURE team working, situational awareness and decision
making. 127 A second training program, Team Strategies
Measurement of the baseline safety culture facilitates an and Tools to Enhance Performance and Patient Safety
action plan for improvement. Safety culture has been (TeamSTEPPS), developed in the US, is designed to
defined as ‘the product of individual and group values, develop competency in four areas: team leadership, situ-
attitudes, perceptions, competencies, and patterns of ational monitoring, mutual support (or back-up beha-
behaviour that determine the commitment to, and the viours) and communication. 128 Thus, training programs
style and proficiency of, an organisation’s health and can be used to help develop various non-technical skills,
121
safety management.’ It is commonly referred to as ‘the ultimately promoting a culture of safety within the criti-
122
way we do things around here.’ A widely used instru- cal care environment.
ment to measure safety culture, the Safety Attitudes Ques-
tionnaire (SAQ), focuses on six domains: teamwork RAPID RESPONSE SYSTEMS
climate, safety climate, job satisfaction, perceptions of
management, working conditions and stress recogni- Rapid Response Systems (RRS) are systems that have
tion. 123 Interestingly, two studies in the USA that used the developed to first recognise, and then to provide emer-
SAQ showed that nurses and doctors differed in their gency response to, patients who experience acute
129,130
perceptions of safety culture. 124,125 deterioration. The Australian Commission on Safety
and Quality in Health Care have identified eight essential
One strategy to improve the safety culture has involved elements in a RRS (Table 3.8). 129
identifying factors that make organisations safe, which in
turn allows initiatives to be developed that target areas of Recently, the recognition aspect of RRS has been referred
specific need. For example, five characteristics of organisa- to as the afferent limb, whereas the response aspect has
131
tions that have been able to achieve high reliability been called the efferent limb. The afferent limb involves
include: 126 the use of various track and trigger systems to identify
patients at risk of deterioration. The efferent limb is com-
1. safety viewed as a priority by leaders prised of teams of specialists who provide treatment and
2. flattened hierarchy that promotes speaking up care to the deteriorating patient. Each of these compo-
about concerns nents is briefly described.
3. regular team training
4. use of effective methods of communicating Afferent Limb
5. standardisation.
Recognising the deteriorating patient, the afferent limb
Many of these five factors fall under the category of has focused on measuring clinical signs including vital
‘non-technical’ skills. 127 Other non-technical skills include signs, level of consciousness and oxygenation as well as
situational awareness and decision making. Importantly acting on abnormalities in these measurements. 129,130 A




TABLE 3.8 Essential elements of a rapid response system 129
Domain Element Description
Clinical Measurement and Vital signs, oxygen saturation and level of consciousness should be undertaken
processes documentation regularly on all acute care patients
Escalation of care A protocol for the organisation’s response in dealing with abnormal physiological
measures and observations including appropriate modifications to nursing care,
increased monitoring, medical review and calling for assistance.
Rapid response systems When severe deterioration occurs, medical emergency teams, outreach teams or
liaison nurses are available to respond.
Clinical communication Structured communication protocols are used to hand over information about the
patient.
Organisational Organisational supports Executive and clinical leadership support and a formal policy framework for
prerequisites recognition and response systems should exist.
Education Education should cover clinical observation, identification of deterioration, escalation
protocols, communication strategies, and skills in initiating early interventions.
Evaluation, audit and Ongoing monitoring and evaluation are required to track changes in outcomes over
feedback time and to check that the RRS is operating as planned.
Technological systems As relevant technologies are developed, they should be incorporated into service
and solutions delivery, after considering evidence of their efficacy and cost as well as potential
unintended consequences.

Quality and Safety 51



TABLE 3.9 Commonly used risk assessment scores

Medical emergency team Modified early warning
(MET) calling criteria 144 Patient-at-risk (PAR) score 136 score (MEWS) 134
Call for all conditions listed Any 3 or more of the following Score of ≥3 requires
Clinical parameter below present referral
Airway threatened – –
Breathing respiratory arrest rate <5/min or Respiratory rate Respiratory rate:
>36/min 1 = 20–29 breaths/min 1 point = 15–20/min
2 = <10 or 30–39 breaths/min 2 points = <8 or 21–29/min
3 = ≥40 breaths/min 3 points = ≥30/min
Oxygen saturation:
1 = 90–94%
2 = 85–89%
3 = <85%
Cardiac cardiac arrest pulse <40/min or Heart rate: Heart rate:
>140/min 1 = 40–49 or 100–114/min 1 = 40–50/min or 101–110/min
2 = 115–129/min 2 = <40/min or 111–129/min
3 = >130/min 3 = ≥130/min
systolic blood pressure (SBP) SBP: SBP:
<90 mmHg 1 = 80–99 mmHg 1 = 81–100 mmHg
2 = 70–79 or ≥180 mmHg 2 = 71–80 or >200 mmHg
3 = <70 mmHg 3 = <70 mmHg
Disability (neurological) decrease in Glasgow Coma Score 1 = confused 1 = responds to voice
>2 repeated/prolonged seizures 2 = responds to voice 2 = responds to pain
3 = responds to pain/unresponsive 3 = unconscious
Other parameters any patient who does not fit the Temperature:
criteria above is causing clinical 1 = 35.0°–35.9° or 37.5°–38.4°C
concern 2 = <35° or >38.5°C
Urine output:
1 = >3 mL/kg/h
2 = <0.5 mL/kg/h
3 = nil








variety of scoring systems to identify ward patients with and ICU Liaison Nurses (LN). RRT is an umbrella term
clinical deterioration have evolved as part of the develop- that refers to the teams responding to deteriorating
ment of critical care outreach, 132 including the MET, 133 patients. In Australia and New Zealand these teams are
131
early warning scoring (EWS), 134 and patient-at-risk (PAR) known as Medical Emergency Teams (MET), while in the
criteria 135,136 (see Table 3.9). United Kingdom they are referred to as Critical Care Out-
Other modified criteria are also in use. 131,137-139 All systems reach Teams (CCOT) and in North America the umbrella
identify abnormalities in commonly measured para- term of RRT is used. Irrespective of the title used, RRT
meters (e.g. respiratory rate, heart rate, blood pressure, generally comprise an experienced nurse and a doctor, and
neurological status). Other parameters used in patient in the case of North America, may include a respiratory
assessment are oxygen saturation, temperature in PAR, therapist. RRT have replaced the traditional ‘cardiac arrest’
urine output in PAR and EWS. The EWS/PAR systems team in many hospitals, although the evidence base on
include an ordinal scoring approach used as calling cri- the effectiveness of the system is not clear. RRT assess
teria for contacting the admitting medical team, ICU staff, deteriorating patients and then initiate emergency treat-
the critical care outreach team or the MET, depending on ments to stabilise patients. Table 3.10 summarises some
the severity of the patient’s clinical deterioration and the of the recent research on RRT. To note, most of the research
resources available in the local clinical environment. has been undertaken in Australia, where MET were first
developed.
The second type of efferent limb service is the ICU
Efferent Limb LN. LN services are a proactive strategy aimed at
The efferent limb involves the response to clinical deterio- ward patients who have complex care needs that
ration. Two types of services have emerged to respond to may overextend the skills of ward staff. 140-142 In some
deteriorating ward patients: Rapid Response Team (RRT) hospitals LNs are part of the RRT. The role of the ICU

52 S C O P E O F C R I T I C A L C A R E



TABLE 3.10 Examples of recent rapid response system research

Study Design Sample Outcome measures Findings
Bristow et al. 2000. Cohort comparison 1510 adverse events Casemix-adjusted rates No significant differences in cardiac arrests
Australia 145 in 3 hospitals (1 MET, of cardiac arrest, (control = 5.1/1000 admissions; MET =
2 control) death, unplanned 3.8) or deaths (18.4 & 15.1 vs 13.3); fewer
ICU readmissions unanticipated ICU readmissions (11.2 &
12/1000 admissions vs 6.4)
Buist et al. 2002. Prospective 19,317 (1996); 22,847 Incidence and outcome 50% reduction in cardiac arrests (before =
Australia 139 before–after (1999) of unexpected 3.8/1000 admissions; MET = 2.1);
cardiac arrest mortality 77% vs 55%
Bellomo et al. 2003. Prospective, All admissions: 21,090 Cardiac arrests, deaths 65% reduction in cardiac arrests (63 vs 22);
Australia 137 controlled (1999); 20,921 57% reduction in deaths from cardiac
before–after (2000–01) to 1 arrest (37 vs 16)
hospital
Bellomo et al. 2004. Prospective, Major surgery (before Adverse events, death, Decrease in adverse outcomes (before =
Australia 146 controlled n = 1116; MET n = hospital length of 301/1000 surgical admissions; MET =
before–after 1067) stay 127); 37% decrease in postoperative
deaths; decreased hospital stay (24 days
vs 20 days)
DeVita et al. 2004. Retrospective, 4489 arrest/MET calls Crisis calls, cardiac Increase in crisis team usage (before =
USA 131 before–after in 1 hospital arrests 14/1000 admissions; MET = 26); 17%
decrease in cardiac arrests (before = 6.5;
MET = 5.4); no change in deaths from
arrests
Hillman et al. 2005. Cluster-randomised 23 hospitals (12 Composite outcome: Similar incidence for composite (control =
Australia 144 controlled trial intervention; 11 cardiac arrest, 7.1/1000 admissions; MET = 6.6) and
control) unexpected death, individual outcomes; calls not associated
unplanned ICU with an event (control = 37%; MET =
readmission 70%); inadequate monitoring and
documentation of unstable patients
noted
Dacey et al. 2007. Prospective All adult admissions to Cardiac arrest, Average cardiac arrests per 1000
USA 147 before–after 1 hospital over 5 unplanned ICU discharges per month decreased from
months admissions, hospital 7.6 before to 3.0 after implementing the
mortality rapid response team; unplanned ICU
admissions decreased from 45% to 29%;
hospital mortality decreased from 2.82%
to 2.35%





LN is described as one of education of both staff and SUMMARY
patients, supervision, follow-up of patients discharged
from ICU, liaison and coordination with ward In summary, this chapter has provided an overview of
staff, assessment, assistance in development and coor- safety and quality in critical care. Evidence-based nursing
dination of the discharge plan, preparation of written is viewed as an important foundation to promote quality
documentation and referral. 143 Despite the broadly as is the development and use of good quality clinical
defined nature of this role, one of its primary practice guidelines. Quality and safety monitoring under-
aspects involves supporting other staff, both within pin understanding the risks that patients face in critical
and beyond the ICU, in providing continuity of care care. The use of care bundles, checklists and information
for ICU patients. 143 The scope of practice, qualifica- and communication technologies may improve quality of
tions and job titles of LNs have yet to be standardised, care. Techniques such as the analysis of clinical incidents,
although a LN Special Interest Group now exists root cause analyses and failure mode and effects analysis
under the auspices of the Australian College of Critical help in understanding situations that place patients at risk
Care Nurses. This group is working to develop a standard of adverse events. One particular high risk scenario is the
role description and core competencies for the LN deteriorating patient, with a number of rapid response
role. Interestingly, while the literature about LNs is pre- systems now being implemented to respond to this sce-
dominantly from Australia and New Zealand, the service nario. Understanding situations that place patients at risk
is now emerging in countries such as Canada and of harm as well as the safety culture of a unit or organisa-
Scotland. tion provide the foundation to improve safety culture.

Quality and Safety 53



Case study
You have just been assigned the role of Quality and Safety Coordina- in this chapter and the related learning activities to prepare a brief
tor for your clinical area. As a part of your role you have been asked project plan outlining how this problem can be addressed. For the
to implement a multi-faceted quality improvement project that purposes of this exercise, focus on what you would include in a
targets hospital-acquired pressure ulcers – a highly prevalent pressure ulcer prevention toolkit (i.e. targeted strategies to improve
adverse event occurring in your unit. Use the information contained care) and how you would evaluate its effectiveness.








Research vignette

Epsin S, Wickson-Griffiths A, Wilson M, Lingard L. To report or not data. The use of scenarios and semi-structured interviews were
to report: A descriptive study exploring ICU nurses’ perceptions of appropriate data collection methods to examine nurses’ percep-
error and error reporting. Intensive and Critical Care Nursing 2010; tions of errors and near misses. The researchers should be com-
26: 1–9. mended on first, training the participants in the ‘think aloud’
Abstract method and then piloting various forms of observational data
Objective collection.
To explore the emergent factors influencing nurses’ error reporting The sample size of 37 nurses, 12–13 from each type of ICU is actu-
preferences, scenarios were developed to probe reporting situa- ally quite large for a predominantly qualitative study, but it allowed
tions in the intensive care unit. the researchers to identify differences in responses based on prac-
Setting tice setting. No information was given on how the participants
Three Canadian intensive care unit settings including: one urban were chosen, although the researchers do identify that predomi-
academic tertiary hospital, one community hospital and one aca- nantly participants were female and varied in levels of experience.
demic paediatric hospital. It would have been helpful to be told exactly how many nurses
were asked the two interview questions that were added later in
Research methodology/design data collection.
Using qualitative descriptive methodology, semi-structured inter-
views were guided by a script which included a series of both In terms of data analysis, it is not clear how the ‘constant compari-
closed and open-ended questions. One near miss and four error son’ method was used to identify primary and secondary themes.
scenarios were used as prompts during interview. Four of the five The constant comparison method is often referred to in grounded
scenarios were identical across all three sites; however, one sce- theory studies, where the researchers move their analysis from
nario differed in the community site to reflect the distinct practice within a single participant, to across participants and to the litera-
environment. ture, using open, axial and selective coding, resulting in the iden-
tification of a core category and other categories. However, in this
Main outcome measures
Three key points of analysis included: nurses’ error perception, study, primary and secondary themes, not categories, were identi-
decision to report the scenario and style of reporting (formal and/ fied. It would have been helpful had a more detailed description
or informal). of how the qualitative analysis was given. On the positive side, it is
commendable that two analysts were used and discrepancies
Results resolved by together returning to the data. Additionally, all themes
At least 81% of the 37 participants stated that they would report were described and explained very well. The quantitative analysis
the events in the respective scenarios. Deviations from standards was straightforward and the table easy to understand, however
of practice emerged as the primary rationale for participants’ per- including raw frequencies in addition to percentages is a sugges-
ception of error. tion for improvement, to make these results more transparent (i.e.
Conclusion missing data could have been identified had raw frequencies been
Nurses working in the intensive care unit readily perceive and are given).
willing to report errors or near misses; however they may choose The researchers should be commended for their insight into the
informal or formal methods to report. limitations of their study. An additional limitation that could have
Critique been mentioned was the fact that what the nurses said they would
The aims of the study were easy to identify and clearly stated. The do and what they really would do in clinical practice may have
researchers explained how this study arose from their previous differed, thus this study reflects the former and not the latter.
research and situated it in the current literature on adverse events However, by providing both Appendices (scenarios and interview
and errors in ICU. While the researchers stated that this study was questions), others could easily replicate their research in other set-
qualitative in nature, the fact that they were able to calculate per- tings. Overall, this study provides new evidence about how critical
centages of responses means that it did involve some quantitative care nurses perceive error in clinical practice.

54 S C O P E O F C R I T I C A L C A R E

12. Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD. Measurement
Learning activities of quality and assurance of safety in the critically ill. Clin Chest Med 2009;
30: 169–79.
13. Wilson RM, Van Der Weyden MB. The safety of Australian healthcare: 10
● Using each domain of quality and safety as headings (i.e. years after QAHS. Med J Aust [editorial] 2005; 182: 260–61.
structure, process, culture, outcome), list some of the key 14. Speroff TP, O’Connor GT. Study designs for PDSA quality improvement
considerations for a quality improvement project targeting research. Qual Manage Health Care 2004; 13(1): 17–32.
pressure ulcer prevention in your unit. 15. Curtis JR, Cook DJ, Wall RJ, Angus DC, Bion J et al. Intensive care unit quality
● Examine the patterns of incidence for a high-frequency improvement: a ‘how-to’ guide for the interdisciplinary team. Crit Care Med
2006; 34: 211–18.
adverse event (e.g. medication error) in your unit over the 16. Ehsani JP, Jackson T, Duckett SJ. The incidence and cost of adverse events in
past 12 months. What were the causes of incidents? What Victorian hospitals 2003–04. Med J Aust 2006; 184(11): 551–5.
targeted strategies could be used to reduce the incidence 17. Runciman WB, Roughead EE, Semple SJ, Adams RJ. Adverse drug events and
medication errors in Australia. Int J Qual Health Care 2003; 15: i49–59.
of these adverse events? 18. Needham DM, Thompson DA, Holzmueller C, Dorman T, Lubomski LH
● Identify and provide a rationale for an aspect of care that et al. A system factors analysis of airway events from the Intensive Care Unit
might benefit from the use of a checklist in your unit. Safety Reporting System (ICUSRS). Crit Care Med 2004; 32(11): 2227–31.
Develop some specific checklist items that you think should 19. Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P. Incidents
be included. relating to the intra-hospital transfer of critically ill patients: an analysis of
● Describe how technology is used in your unit to improve the reports submitted to the Australian Incident Monitoring Study in Inten-
sive Care. Intens Care Med 2004; 30(8): 1579–85.
care delivered to patients. Using the information outlined 20. Capuzzo M, Nawfal I, Campi M, Valpondi V, Verri M, Alvisi R. Reporting of
in the section on information and communication tech- unintended events in an intensive care unit: comparison between staff and
nologies, identify where there is potential to use technol- observer. BMC Emerg Med 2005; 5(1): 1–7.
ogy to improve care delivery further. Use examples specific 21. Wolff AM, Bourke J, Campbell IA, Leembruggen DW. Detecting and reducing
hospital adverse events: outcomes of the Wimmera clinical risk management
to your unit. program. Med J Aust 2001; 174: 621–5.
22. Beckmann U, West L, Groombridge GJ, Baldwin I, Hart GK et al. The Aus-
tralian Incident Monitoring study in Intensive Care: AIMS-ICU. The develop-
ment and evaluation of an incident reporting system in intensive care. Anaesth
Intens Care 1996; 24(3): 314–19.
ONLINE RESOURCES 23. Baldwin I, Beckmann U, Shaw L, Morrison A. Australian incident monitoring
study in intensive care: local unit review meetings and report management.
Anaesth Intens Care 1998; 26: 294–7.
Agency for Healthcare Research and Quality, http://www.ahrq.gov 24. Classen DC, Metzger J. Improving medication safety: the measurement
Australian Commission on Safety and Quality in Health Care (ACSQHC), http:// conundrum and where to start. Int J Qual Health Care 2003; 15: i41–47.
www.safetyandquality.gov.au 25. Koppel R. What do we know about medication errors via a CPOE system
Australian Council on Healthcare Standards (ACHS), http://www.achs.org.au/ versus those made via handwritten orders? Crit Care 2005; 9: R516–17.
Intensive Care Coordination and Monitoring Unit (ICCMU), New South Wales 26. Beckmann U, Bohringer C, Carless R, Gillies DM, Runciman WB, Pronovost
Health, http://intensivecare.hsnet.nsw.gov.au PJ. Evaluation of two methods for quality improvement in intensive care:
Institute for Healthcare Improvement (IHI), USA, http://www.ihi.org/ihi facilitated incident monitoring and retrospective medical chart review. Crit
The Joint Commission (USA), http://www.jointcommission.org/ Care Med 2003; 31(4): 1006–11.
National E-Health Transition Authority, http://www.nehta.gov.au/ 27. Taxis K, Barber N. Ethnographic study of incidence and severity of intrave-
National Health and Medical Research Council, http://www.nhmrc.gov.au/ nous drug errors. BMJ 2003; 326: 684–7.
National Quality Forum, http://www.qualityforum.org/ 28. Malashock CM, Shull SS, Gould DA. Effect of smart infusion pumps on
World Health Organization Patient Safety, http://www.who.int/patientsafety/en medication errors related to infusion device programming. Hosp Pharm
2004; 39: 460–69.
REFERENCES 29. Rothschild J, Landrigan CP, Cronin JW, Kaushal R, Lockley SW et al. The
Critical Care Safety Study: the incidence and nature of adverse events and
1. Valentin A, Capuzzo M, Guidet B, Moreno R, Dolanski L et al. Patient safety serious medical errors in intensive care. Crit Care Med 2005; 33(8):
in intensive care: results from the multinational Sentinel Events Evaluation 1694–1700.
(SEE) study. Intens Care Med 2006; 32: 1591–8. 30. Apkon M, Leonard J, Probst L, DeLizio L, Vitale R. Design of a safer approach
2. Lohr K, Schroeder S. A strategy for quality assurance in medicine. New Engl to intravenous drug infusions: failure mode effects analysis. Qual Saf Health
J Med 1990; 322: 1161–71. Care 2003; 13: 265–71.
3. Rogers AE, Dean GE, Hwang WT, Scott LD. Role of registered nurses in error 31. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of
prevention, discovery and correction. Qual Safe Health Care 2008; 17: interruptions with an increased risk and severity of medication administra-
117–21. tion errors. Arch Intern Med 2010; 170(8): 683–90.
4. Cullum N, Cilicska D, Haynes RB, Marks S. Evidence-based nursing: an intro- 32. Kliger J. Giving medication administration the respect it is due: comment
duction. Oxford, UK: Blackwell Publishing; 2008. on “association of interruptions with an increased risk and severity of medi-
5. National Health and Medical Research Council. How to use the evidence: cation administration errors”. Arch Intern Med [Invited Commentary] 2010;
assessment and application of scientific evidence. Canberra: Commonwealth of 170(8): 690–92.
Australia; 2000. 33. Australian and New Zealand Intensive Care Society, Australian Council on
6. Jennings BM, Loan LA. Misconceptions aming nurses about evidence-based Healthcare Standards. Intensive care indicators. Sydney: ACHS; 2011.
practice. J Nurs Scholarsh 2001; 33(2): 121–7. 34. Esmail R, Kirby A, Inkson T, Boiteau P. Quality improvement in the ICU: a
7. Grol R, Grimshaw J. From best evidence to best practice: effective implemen- Canadian perspective. J Crit Care 2005; 20: 74–8.
tation of change in patients’ care. Lancet 2003; 362: 1225–30. 35. Ilan R, Fowler R. Brief history of patient safety culture and science. J Crit Care
8. Ilott I, Rick J, Patterson M, Turgoose C, Lacey A. What is protocol-based care? 2005; 20: 2–5.
A concept analysis. J Nurs Manag 2006; 14: 544–52. 36. Pronovost PJ, Rinke ML, Emery K, Dennison C, Blackledge C, Berenholtz S.
9. Miller M, Kearney N. Guidelines for clinical practice: development, dissemi- Interventions to reduce mortality among patients treated in intensive care
nation and implementation. Int J Nurs Stud 2004; 41: 813–21. units. J Crit Care 2004; 19(3): 158–64.
10. Intensive Care Coordination and Monitoring Unit. New South Wales 37. Pronovost PJ, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C.
Department of Health; 2010 [Cited March 2011]. Available from: http:// Improving communication in the ICU using daily goals. J Crit Care 2003;
intensivecare.hsnet.nsw.gov.au/state-wide-guidelines. 18(2): 71–5.
11. Donabedian A. Evaluating the Quality of Medical Care. Milbank Q 2005; 38. Pronovost PJ, Holzmueller C. Partnering for quality. J Crit Care 2004; 19(3):
44(3): 691–729. 121–9.

Quality and Safety 55

39. Vincent J-L. Give your patient a FAST HUG (at least) once a day. Crit Care 67. Davidson P, Daly J, Romanini J, Elliott D. Quality use of medicines (QUM)
Med 2005; 33(6): 1225–9. in critical care: an imperative for best practice. Aust Crit Care 2001; 14:
40. Crunden E, Boyce C, Woodman H, Bray B. An evaluation of the impact of 122–6.
the ventilator care bundle. Nurs Crit Care 2005; 10(5): 242–6. 68. Wilson K, Sullivan M. Preventing medication errors with smart infusion
41. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a technology. Am J Health Syst Pharm 2004; 61: 177–83.
bundle approach to improve ventilator care processes and reduce ventilator- 69. Rothschild JM, Keohane CA, Cook EF, Orav EJ, Burdick E et al. A controlled
associated pneumonia. J Qual Pat Saf 2005; 31(5): 243–8. trial of smart infusion pumps to improve medication safety in critically ill
42. Papadimos T, Hensley S, Duggan J, Khuder S, Borst M et al. Implementation patients. Crit Care Med 2005; 33: 533–40.
of the “FASTHUG” concept decreases the incidence of ventilator-associated 70. Manjoney R. Clinical information systems market: an insider’s view. J Crit
pneumonia in a surgical intensive care unit. Pat Saf Surg 2008; 2(1): 3. Care 2004; 19: 215–20.
43. Hatler CW, Mast D, Corderella J, Mitchell G, Howard K et al. Using evidence 71. Marasovic C, Kenney C, Elliott D, Sindhusake D. A comparison of nursing
and process improvement strategies to enhance healthcare outcome for the activities associated with manual and automated documentation in an Aus-
critically ill: A pilot project. Am J Crit Care 2006; 15(6): 549–55. tralian intensive care unit. Comput Nurs 1997; 15(4): 205–11.
44. Wall RJ, Ely EW, Elasy TA, Dittus RS, Foss J et al. Using real time process 72. Wong DH, Gallegos Y, Weinger MB, Clack S, Slagle J, Anderson CT. Changes
measurements to reduce catheter related bloodstream infections in the in intensive care unit nurse task activity after installation of a third-generation
intensive care unit. Qual Saf Health Care 2005; 14: 295–302. intensive care unit information system. Crit Care Med 2003; 31(10): 2488–
45. Keroack MA, Cerese J, Cuny J, Bankowitz R, Neikirk HJ, Pingleton SK. The 94.
relationship between evidence-based practices and survival in patients 73. Fraenkel DJ, Cowie M, Daley P. Quality benefits of an intensive care clinical
requiring prolonged mechanical ventilation in academic medical centers. Am information system. Crit Care Med 2003; 31(1): 120–25.
J Med Qual 2006; 21: 91–100. 74. Marasovic C, Kenney C, Elliott D, Sindhusake D. Attitudes of Australian
46. Clemmer TP, Spuhler VJ, Oniki TA, Horn SD. Results of a collaborative nurses towards the implementation of a clinical information system. Comput
quality improvement program on outcomes and costs in a tertiary critical Nurs 1997; 15: 91–8.
care unit. Crit Care Med 1999; 27(9): 1768–74. 75. Ward NS, Snyder JE, Ross S, Haze D, Levy MM. Comparison of a commer-
47. Ilan R, Fowler RA, Geerts R, Pinto R, Sibbald WJ, Martin CM. Knowledge cially available clinical information system with other methods of measuring
translation in critical care: Factors associated with prescription of commonly critical care outcomes data. J Crit Care 2004; 19(1): 10–15.
recommended best practices for critically ill patients. Crit Care Med 2007; 76. Ash JS, Berg M, Coiera E. Some unintended consequences of information
35(7): 1696–702. technology in health care: the nature of patient care information system-
48. Hales BM, Pronovost P. The checklist – a tool for error management and related errors. J Am Med Inform Assoc 2004; 11(2): 104–12.
performance improvement. J Crit Care 2006; 21: 231–5. 77. Van der Sijs H, Aarts J, Vulto A. Overriding of drug safety alerts in com-
49. Dobkin E. Checkoffs play key role in SICU improvement: checklist helps puterized physician order entry. J Am Med Inform Assoc 2006; 13(2):
team follow care plan. Healthcare Benchmarks Qual Improv [serial on the 138–47.
Internet] 2003. Available from: http://findarticles.com/p/articles/mi_ 78. Frassica JJ. CIS: Where are we going and what should we demand from
m0NUZ/is_10_10/ai_109026749/?tag=content;col1. industry? J Crit Care 2004; 19(4): 226–33.
50. Piotrowski MM, Hinshaw DB. The safety checklist program: creating a 79. Rothschild J. Computerized physician order entry in the critical care and
culture of safety in intensive care units. Jt Comm J Qual Improv 2002; 28(6): general inpatient setting: a narrative review. J Crit Care 2004; 19(4):
306–15. 271–8.
51. Ursprung R, Gray JE, Edwards WH, Horbar JD, Nickerson J et al. Real time 80. Christian S, Gyves H, Manji M. Electronic prescribing. Care Crit Ill 2004; 20:
patient safety audits: improving safety every day. Qual Saf Health Care 2005; 68–71.
14: 284–9. 81. Ali NA, Mekhjian HS, Kuehn PL, Bentley TD, Kumar R et al. Specificity
52. Pronovost PJ, Berenholtz S, Ngo K, McDowell M, Holzmueller C et al. of computerized physician order entry has a significant effect on the effi-
Developing and pilot testing quality indicators in the intensive care unit. ciency of workflow for critically ill patients. Crit Care Med 2005; 33(1):
J Crit Care 2003; 18(3): 145–55. 110–14.
53. Hewson KM, Burrell AR. A pilot study to test the use of a checklist in a tertiary 82. Perez F, Winters JL, Gajic O. The addition of decision support into computer-
intensive care unit as a method of ensuring quality processes of care. Anaesth ized physician order entry reduces red blood cell transfusion resource utiliza-
Intens Care. 2006; 34: 322–8. tion in the intensive care unit. Am J Hematol 2007; 82(7): 631–3.
54. DuBose JJ, Inaba K, Shiflett A, Trankiem C, Teixeira P et al. Measureable 83. Thursky KA, Buising K, Bak N, Macgregor L, Street AC et al. Reduction
outcomes of quality improvement in the trauma intensive care unit: The of broad-spectrum antibiotic use with computerized decision support
impact of a daily quality rounding checklist. J Trauma 2008; 64: 22–9. in an intensive care unit. Int J Qual Health Care 2006; 18(3):
55. Byrnes MC, Schuerer DJE, Schallom ME, Sona CS, Mazuski JE et al. Imple- 224–31.
mentation of a mandatory checklist of protocols and objectives improves 84. Sintchenko V, Iredell JR, Gilbert GL, Coiera E. Handheld computer-based
compliance with a wide range of evidence-based intensive care unit practices. decision support reduces patient length of stay and antibiotic prescribing in
Crit Care Med 2009; 37(10): 1–7. critical care. J Am Med Inform Assoc 2005; 12(4): 398–402.
56. Hart EM, Owen H. Errors and omissions in anesthesia: A pilot study using 85. Eslami S, De Keizer NF, Abu-Hanna A, De Jonge E, Schultz MJ. Effect of a
a pilot’s checklist. Anesth Analg 2005; 101: 246–50. clinical decision support system on adherence to a lower tidal volume
57. Hewson-Conroy KM, Elliott D, Burrell AR. Quality and safety in intensive mechanical ventilation strategy. J Crit Care 2009; 24: 523–9.
care – A means to an end is critical. Aust Crit Care 2010; 23(3): 109– 86. Lyerla F, LeRouge C, Cooke DA, Turpin D, Wilson L. A nursing clinical deci-
29. sion support system and potential predictors of head-of-bed position for
58. Australian Health Ministers’ Conference. National E-Health strategy summary. patients receiving mechanical ventilation. Am J Crit Care 2010; 19(1):
Melbourne, Australia; December 2008. 39–47.
59. National E-Health Transition Authority. NEHTA Strategic Plan 2009/10 to 87. Sim I, Gorman P, Greenes RA, Haynes RB, Kaplan B et al. Clinical decision
2011/12. Sydney, Australia; November 2009. support systems for the practice of evidence-based medicine. J Am Med
60. Lee T-T. Nurses’ adoption of technology: application of Rogers’ innovation- Inform Assoc 2001; 8(6): 527–34.
diffusion model. Appl Nurs Res 2004; 17(4): 231–8. 88. Sucher JF. Computerized clinical decision support: a technology to imple-
61. Ward NS. The accuracy of clinical information systems. J Crit Care 2004; ment and validate evidence based guidelines. J Trauma [Review article] 2008;
19(4): 221–5. 64(2): 520–37.
62. Clemmer TP. Computers in the ICU: Where we started and where we are 89. Overhage M, Tierney WM, Zhou X, McDonald CJ. A randomized trial of
now. J Crit Care 2004; 19(4): 201–7. ‘corollary orders’ to prevent errors of omission. J Am Med Inform Assoc 1997;
63. Seiver A. ICU bedside technology: past, present and future. Crit Care Clin 4: 364–75.
2000; 16: 601–21. 90. Kucher N, Koo S, Quiroz R, Cooper JM, Paterno MD et al. Electronic alerts
64. Levy MM. Computers in the intensive care unit. J Crit Care 2004; 19(4): to prevent venous thromboembolism among hospitalized patients. New Engl
199–200. J Med 2005; 352(10): 969–77.
65. Clemmer TP. Monitoring outcomes with relational databases: does it 91. van Wyk JT, van Wijk AM, Sturkenboom MCJM, Mosseveld M, Moorman
improve quality of care? J Crit Care 2004; 19(4): 243–7. PW, van der Lei J. Electronic alerts versus on-demand decision support to
66. Rubenfeld GD. Using computerized medical databases to measure and to improve dyslipidemia treatment. A cluster randomized controlled trial. Cir-
improve the quality of intensive care. J Crit Care 2004; 19(4): 248–56. culation 2008; 117: 371–8.

56 S C O P E O F C R I T I C A L C A R E

92. Coleman RW. Translation and interpretation: the hidden processes and 120. McDonough JE. Proactive hazard analysis and health care policy. New York:
problems revealed by computerized physician order entry systems. J Crit Care Milbank Memorial Fund; 2002.
2004; 19(4): 279–82. 121. Sorro JS, Nieva VF. Hospital survey on patient safety culture. Rockville, MD:
93. Tooey MJ, Mayo A. Handheld technologies in a clinical setting: state of the Agency for Healthcare Research and Quality; 2004.
technology and resources. AACN Clin Issues 2003; 14: 342–9. 122. Davies HT, Nutley SM, Mannion R. Organisational culture and quality of
94. Craig AE. PDAs and smartphones: clinical tools for nurses. Medscape Business health care. Qual Health Care 2000; 9: 111–19.
of Medicine [serial on the Internet] 2009. Available from: www.medscape.com. 123. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K et al. The Safety
95. Lapinsky S, Wax R, Showater R, Martinez-Motta JC, Hallett DC et al. Prospec- Attitudes Questionniare: psychometric properties, benchmarking data, and
tive evaluation of an internet-linked handheld computer critical care knowl- emerging research. BMC Health Serv Res 2006; 6(44): 1472–82.
edge access system. Crit Care 2004; 8: R414–21. 124. Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork
96. George LE, Davidson LJ, Serapiglia CP, Barla S, Thotakura A. Technology in among critical care nurses and physicians. Crit Care Med 2003; 31(3):
nursing education: A study of PDA use by students. J Prof Nurs 2010; 26(6): 956–9.
371–6. 125. Huang DT, Clermont G, Sexton JB, Karlo CA, Miller RG et al. Perceptions of
97. Kuiper RA. Metacognitive factors that impact student nurse use of point of safety culture vary across the intensive care units of a single institution. Crit
care technology in clinical settings. Int J Nurs Educ Schol 2010; 7(1): 1–15. Care Med 2007; 35(1): 165–76.
98. Martinez-Motta JC, Walker RG, Stewart TE, Granton J, Abrahamson S, 126. Clarke JR, Lerner JC, Marella W. The role for leaders of health care organiza-
Lapinsky SE. Critical care procedure logging using handheld computers. tions in patient safety. Am J Med Qual 2007; 22(5): 311–18.
Crit Care 2004; 8(5): R336–42. 127. Reader T, Flinn R, Lauche K, Cuthbertson BH. Non-technical skills in the
99. Bochicchio GV, Smit PA, Moore R, Bochicchio K, Auwaerter P et al. Pilot intensive care unit. Br J Anaesth 2006; 96(5): 551–9.
study of a web-based antibiotic decision management guide. J Am Coll Surg 128. Clancy CM, Tornberg DN. TeamSTEPPS: Assuring optimal teamwork in clini-
2006;202 (3): 459–67. cal settings. Am J Med Qual 2007; 22: 214–17.
100. Iregui M, Ward S, Clinikscale D, Clayton D, Kollef MH. Use of a handheld 129. Australian Commission on Safety and Quality in Health Care. National
computer by respiratory care practitioners to improve the efficiency of Consensus Statement: Essential Elements for Recognising and Responding to Clini-
weaning patients from mechanical ventilation. Crit Care Med 2002; 30(9): cal Deterioration. Sydney: ACSQHC; 2010.
2038–43. 130. National Institute for Health and Clinical Excellence. Acutely Ill Patients in
101. Rosenfeld B, Dorman T, Breslow M, Pronovost PJ, Jenckes MW et al. Intensive Hospital: Recognition of and Response to Acute Illness in Adults in Hospital.
care unit telemedicine: alternate paradigm for providing continuous inten- London: Author; 2007.
sivist care. Crit Care Med 2000; 28(12): 3925–31. 131. DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M et al. Use of
102. Afessa B. Tele-intensive care unit: the horse out of the barn. Crit Care Med medical emergency team responses to reduce hospital cardiopulmonary
[Editorial] 2010; 38(1): 292–3. arrests. Qual Safe Health Care 2004; 13: 251–4.
103. Breslow M, Rosenfeld B, Doerfler M, Burke G, Yates G et al. Effect of a 132. McArthur-Rouse F. Critical care outreach services and early warning scoring
multiple-site intensive care unit telemedicine program on clinical and eco- systems: a review of the literature. J Adv Nurs 2001; 36: 696–704.
nomic outcomes: An alternative paradigm for intensivist staffing. Crit Care 133. Lee A, Bishop G, Hillman KM, Daffurn K. The medical emergency team.
Med 2004; 32(1): 31–8. Anaesth Intens Care 1995; 23: 183–6.
104. Vespa PM, Miller C, Hu X, Nenov V, Buxey F, Martin NA. Intensive care unit 134. Morgan RJM, Williams F, Wright MM. An early warning scoring system for
robotic telepresence facilitates rapid physician response to unstable patients detecting developing critical illness. Clin Intens Care 1997; 8: 100.
and decreased cost in neurointensive care. Surg Neurol 2006; 67(2007): 135. Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient
331–7. at risk team: identifying and managing seriously ill ward patients. Anesth
105. Westbrook J, Coiera EW, Brear M, Stapleton S, Rob M et al. Impact of an 1999; 55: 853–60.
ultrabroadband emergency department telemedicine system on the care of 136. Goldhill DR, McNarry AF, Mandersloot G, McGinley A. A physiologically-
acutely ill patients and clinicians’ work. Med J Aust [Research] 2008; 188(12): based early warning score for ward patients: the association between score
704–8. and outcomes. Anesth 2005; 60: 547–53.
106. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedi- 137. Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart GK et al. A prospec-
cine for remote monitoring of intesive care patients with mortality, compli- tive before-and-after trial of a medical emergency team. Med J Aust 2003;
cations, and length of stay. J Am Med Assoc 2009; 302(24): 2671–8. 179: 283–7.
107. Morrison JL, Cai Q, Davis N, Yan Y, Berbaum ML et al. Clinical and economic 138. Hodgetts TJ, Kenward G, Vlackonikolas I, Payne S, Castle N. The indentifica-
outcomes of the electronic intensive care unit: results from two community tion of risk factors for cardiac arrest and formulation of activation criteria to
hospitals. Crit Care Med 2010; 38(1): 2–8. alert a medical emergency team. Resusc 2002; 54: 125–31.
108. Yoo JS, Dudley RA. Evaluating telemedicine in the ICU. J Am Med Assoc 2009; 139. Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV.
302(24): 2705–6. Effects of a medical emergency team on reduction of incidence of and mor-
109. Curran VR. Tele-education. J Telemed Telecare 2006; 12(2): 57–63. tality from unexpected cardiac arrests in a hospital: a preliminary study. BMJ
110. Simpson RL. See the future of distance education. Nurs Manage 2006; 37(2): 2002; 324: 387–90.
42, 44, 46–51. 140. UK NHS Modernisation Agency. The National Outreach Report. London: UK
111. Beeckman D, Schoonhoven L, Boucque H, Van Maele G, Defloor T. Pressure Department of Health; 2003.
ulcers: e-learning to improve classification by nurses and nursing students. 141. Chaboyer W, James H, Kendall M. Transitional care after the intensive
J Clin Nurs 2008; 17(13): 1697–707. care unit: current trends and future directions. Crit Care Nurs 2005; 25:
112. Maag M. The potential use of “blogs” in nursing education. Comput Inform 1–10.
Nurs 2005; 23(1): 16–24. 142. Chaboyer W, Foster MM, Foster M, Kendall E. The intensive care unit liaison
113. Kreideweis J. Indicators of success in distance education. Comput Inform Nurs nurse: towards a clear role description. Intens Crit Care Nurs 2004; 20:
2005; 23(2): 68–72. 77–86.
114. Moreno RP, Rhodes A, Donchin Y. Patient safety in intensive care medicine: 143. Russell S. Reducing readmissions to the intensive care unit: employment of
The Declaration of Vienna. Intens Care Med 2009; 35: 1667–72. a follow-up nurse. Heart & Lung 1999; 28: 365–72.
115. Institute of Medicine. Crossing the quality chasm: A new health system for the 144. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D et al. Introduction of
21st century. Washington, DC: National Academy Press; 2001. the medical emergency team (MET) system: a cluster-randomised controlled
116. Institute of Medicine. Patient safety: Achieving a new standard of care. trial. Lancet. 2005; 365: 2091–7.
Washington DC: National Academy Press; 2003. 145. Bristow PJ, Hillman KM, Chey T, Daffum K, Jacques T. Rates of in-hospital
117. European Agency Safety Improvement for Patients in Europe (SIMPATIE). arrests, deaths and critical care admissions: the effect of the medical emer-
Cited 1 February 2010. Available from: http://www.simpatie.org. gency team. Med J Aust 2000; 173: 236–50.
118. Bagian JP, Gosbee J, Lee CZ, Williams L, McKnight SD, Mannos DM. The 146. Bellomo R, Goldsmith D, Uchino S. Prospective controlled trial of effect of
Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv medical emergency team on postoperative morbidity and mortality rates.
2002; 28: 531–45. Crit Care Med 2004; 32: 916–21.
119. Middleton S, Walker C, Chester R. Implementing root cause analysis in an 147. Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J et al. The effect of a rapid
area health service: views of the participants. Aust Health Rev 2005; 29: response team on major clinical outcome measures in a community hospi-
422–8. tal. Crit Care Med 2007; 35(9): 2076–82.

Recovery and Rehabilitation 4





Doug Elliott
Janice Rattray



reconsideration and re-conceptualisation of critical care
Learning objectives as only one component in the continuum of care for a
critically ill patient. An episode of critical illness is now
After reading this chapter, you should be able to: viewed as a continuum that begins with the onset of acute
● discuss the physical, psychological and cognitive sequelae clinical deterioration, includes the ICU admission, and
present for some survivors of a critical illness continues until the patient’s risk of late sequelae has
● outline the common functional, psychological and returned to the baseline risk of a similar individual who
9
health-related quality of life (HRQOL) instruments used to has not incurred a critical illness (see Figure 4.1). Timing
assess patient outcomes after a critical illness of this recovery trajectory is variable, and related to a
● describe the benefits and challenges for implementing number of individual, illness and treatment factors.
rehabilitation interventions in-ICU, in hospital after Reviews of numerous observational studies confirm
ICU-discharge, and after hospital discharge delayed recovery in HRQOL, e.g.3-5 with both physical and
psychological symptoms prevalent:
6
● weakness: 46% ; 25–60% in patients ventilated
>7 days 10
● delirium: up to 67% 11
Key words ● anxiety: 12–43% 12
● depression: median 28% 13
cognitive dysfunction ● posttraumatic stress symptoms: 5–64% 14
health-related quality of life (HRQOL) The effects of a critical illness on cognitive functioning
intensive care unit-acquired weakness (ICU-AW) are now also beginning to be examined and discussed in
posttraumatic stress symptoms the literature as an important patient outcome. 11,15-19
psychological sequelae While significant sequelae therefore exist for a substantial
proportion of critical illness survivors, little evidence is
currently available to support specific interventions for
improving their recovery. 9,20
INTRODUCTION A further and more recent re-conceptualisation of holistic
critical care practice promotes a unifying approach for
A critical illness requiring admission to a general inten-
sive care unit (ICU) affects approximately 113,000 adults minimising intensive care unit acquired weakness (ICU-
11,21
1
in Australia and 17,000 in New Zealand per year. AW) and delirium, reflected in the acronym ABCDE,
Although survival rates approximate 89% at hospital dis- to minimise physical, psychological and cognitive
2
charge, functional recovery for individuals is delayed sequelae:
3-5
often beyond six months post-discharge. Physical A Awaken the patient daily
6,7
de-conditioning and neuromuscular dysfunction as B Breathing trials (to minimise mechanical ventila-
8
well as psychological sequelae are common, adding to tion duration)
the burden of illness for survivors, carers, the health care C Coordination (of daily awakening and spontane-
system and broader society. 9 ous breathing trials) 22
D Delirium monitoring
While ICU clinicians have traditionally focused on sur-
vival as the principal indicator of patient outcome and E Exercise/Early mobility (requires a patient to be
9
unit performance, physical and psychological function- awake, alert and co-operative).
ing and health-related quality of life (HRQOL) have now Further chapters in this book discuss psychological issues
emerged as legitimate patient outcomes from both prac- including sedation management and delirium monitor-
4
tice and research perspectives. With this shifting focus ing while in ICU (Chapter 7), and breathing trials and
towards long-term health and wellbeing has also come a weaning from mechanical ventilation (Chapter 15). This 57

58 S C O P E O F C R I T I C A L C A R E

recovering from Acute Lung Injury/Adult Respiratory Dis-
Pre-ICU
Post-hospital
ICU
Ward
29-31
A related factor is nutrition, with one
tress Syndrome.
Disease burden study noting that 39% of patients post-ICU had little or
no appetite and 15% were still receiving either a soft diet
32
or tube feeding while in hospital.
Clinical assessment includes identification of generalised
Time CLINICAL ASSESSMENT
weakness following the onset of a critical illness, exclu-
Burden of critical illness sion of other diagnoses (e.g. Guillain–Barré syndrome),
FIGURE 4.1 The continuum of critical illness. 9 and measurement of muscle strength. Patients suspected
of ICU-AW have diffuse flaccid weakness that is symmetri-
cal and involves both proximal and distal muscles, with
relative sparing of cranial nerves and variable deep tendon
chapter discusses common physical and psychological reflex responses. 23
sequelae associated with a critical illness, and how this Manual Muscle Testing (MMT) is commonly assessed
impacts on a survivor’s HRQOL. Common instruments using the Medical Research Council (MRC) Scale, a 0–5
33
measuring physical, psychological and HRQOL are point ordinal scale:
described. Physical rehabilitation strategies, commencing
with exercise and early mobility in-ICU, post-ICU and 0 = no muscle contraction
post-hospital services are also discussed. 1 = flicker or trace of muscle contraction
2 = active movement with gravity eliminated
ICU-ACQUIRED WEAKNESS 3 = reduced power but active movement against gravity
4 = reduced power but active movement against gravity
Critical illness myopathy (CIM), polyneuropathy (CIP) and resistance
23
and neuromyopathy (CINM) syndromes occur in 46% 5 = normal power against full resistance.
of ICU survivors. More recently, ICU-Acquired Weakness For patients who are awake and cooperative, each muscle
6
(ICU-AW) has been proposed as a term to encompass group is assessed sequentially for strength and
these syndromes of muscle wasting and functional weak- symmetry:
ness in patients with a critical illness who have no other
24
plausible aetiology. The three syndromes above form ● upper limb: deltoid, biceps, wrist extensors
the sub-categories of ICU-AW, with CINM used when ● lower limb: quadriceps, gluteus maximus, ankle
both myopathy and axonal polyneuropathy are evident. dorsiflexion 34
Development of ICU-AW is associated with a number of Weakness is evident with an MRC total score of <48
risk factors: 24-26
(<4 in all testable muscle groups), and re-tested after
● co-existing conditions: chronic obstructive pulmonary 24 hours. Weakness (<4 MRC Scale) was associated with
34
disease, congestive heart failure, diabetes mellitus an increased hospital mortality. Inter-rater reliability
● critical illness: sepsis, systemic inflammatory response following appropriate training using the MRC has
syndrome (SIRS) been demonstrated. 35
● treatments: mechanical ventilation, hyperglycaemia, Hand-held dynamometry enables measurement of grip
glucocorticoids, sedatives, neuromuscular blocking strength force using a calibrated device for patients who
agents, immobility. are conscious and cooperative. Dynamometry was dem-
Local and systemic inflammation acts synergistically with onstrated to be a reliable, rapid and simple alternative to
34
bed rest and immobility to alter metabolic and structural comprehensive MMT assessment, and may be a surro-
27
function of muscles, resulting in muscle atrophy and gate measure for global strength. 24
26
contractile dysfunction, loss of flexibility, CIP, hetero-
topic ossification and entrapment neuropathy. Muscle DIAGNOSTIC TESTING
6
strength can reduce by 1–1.5% per day with a total loss
of 25–50% of body strength possible following immo- Electrophysiological testing (nerve conduction studies,
bilisation. Patients can lose 2% of muscle mass per day, needle electromyography) may be useful as an adjunct in
28
which contributes to weakness and disability, and a pro- diagnosing ICU-AW, but differentiating between CIM and
24
25
longed recovery period. These neuromuscular dysfunc- CIP is difficult. Muscle wasting is a consequence of
tions are diagnosed by clinical assessment, diagnostic inflammatory responses (including COPD-associated
25
studies (electrophysiology, ultrasound) or histology of inflammation). Histology for CIP is primarily noted as
muscle or nerve tissue. 24 distal axonal degeneration in both sensory and motor
fibres, while the characteristic findings in CIM is
The syndrome manifests as prolonged weaning time, patchy loss of myosin (thick filaments), necrosis and fast
24
inability to mobilise and reduced functional capacity. twitch fibre atrophy. Ultrasound is also being examined
Some groups of ICU survivors report relatively poor as a reliable assessment of muscle mass/volume in this
HRQOL due to prolonged weakness that may persist for cohort, although findings can be confounded by tissue
months and years after discharge, particularly for those oedema. 24

Recovery and Rehabilitation 59

HRQOL instruments available is large, but can be divided
Practice tip into two groups: generic to all illnesses, or specific to a
particular disease state. One limitation of generic instru-
Current clinical recommendations to limit muscle wasting ments is that, while they can be applied to a broad spec-
include: trum of populations, they may not be responsive to
● minimising patient exposure to corticosteroids and neuro- specific disease characteristics. This section discusses the
43
muscular blocking agents measurement of health outcomes, focusing on HRQOL,
● limiting excessive analgesia and sedation and the physical and psychological measures commonly
● glycaemic control may also be of value, although further used to assess survivors of a critical illness.
investigations continue
● early nutrition or specific nutritional supplements or com- As introduced earlier, reviews of numerous observational
ponents may limit loss of muscle mass or enhance muscle studies with survivors of a critical illness have demon-
recovery, but also requires further research. 25 strated a delayed recovery trajectory, highlighting particu-
larly the effect of physical function on an individual’s
usual role. Recommendations for future studies noted
that patients should be followed for at least six months,
PATIENT OUTCOMES FOLLOWING have neuropsychological testing as part of their assess-
ment, and be assessed using a HRQOL instrument that
A CRITICAL ILLNESS enables comparison across countries and languages. 3,9,44,45
Common instruments used to assess HRQOL, physical
Examination of patient outcomes beyond survival is an
important contemporary topic for critical care practice functioning and psychological functioning for cohorts of
and research. 3-5,36 Patient outcomes after a critical illness patients after a critical illness are discussed below.
or injury were traditionally measured using a number of
objective parameters (e.g. number of organ failure-free MEASURES OF HEALTH-RELATED QUALITY OF
37
days, 28-day status, or 1-year mortality). Other mea- LIFE AFTER A CRITICAL ILLNESS
sures that examined patient-centred concepts such as A generic instrument that measures baseline HRQOL and
functional status and HRQOL 38,39 have become more exhibits responsiveness in a recovering critically ill patient
prevalent in the literature. 3,4,40-42 As the recovery trajectory with demonstrated reliability and validity has been
from a critical illness may be long and incomplete, elusive, although recent review papers have identified
4,9
mapping this path is a complex process. The range of some useful instruments (see Table 4.1). SF-36 is the




TABLE 4.1 Summary of health-related quality of life (HRQOL) instruments used for patients following a critical illness

Instrument Items Concepts/domains
Medical outcomes study (SF-36) 162,163 36 physical: functioning, role limitations, pain, general health; mental: vitality, social, role
limitations, mental health; health transition; variable response levels (2–5)
EuroQol 5D 46,164 5 mobility, self-care, usual activities, pain/discomfort, anxiety/depression; 3 response
levels; cost-utility index
15D 46,165 15 mobility, vision, hearing, breathing, sleeping, eating, speech, elimination, usual
activities, mental function, discomfort, distress, depression, vitality, and sexual
activity; 5-point ordinal scale (1 = full function; 5 = minimal/no function)
Quality of life–Italian (QOL–IT) 166 5 physical activity; social life; perceived quality of life; oral communication; functional
limitation; varied response levels (4–7)
Assessment of Quality of Life (AQOL) 167 15 Illness (3 items); independent living (3 items); physical senses (3 items); social
relationships (3 items); psychological wellbeing (3 items); 4 response levels; enables
cost-utility analysis
Quality of life–Spanish (QOL–SP) 168 15 basic physiological activities (4 items); normal daily activities (8 items); emotional
state (3 items)
Sickness impact profile (SIP) 169 68 physical: somatic autonomy; mobility control; mobility range
psychosocial: psychic autonomy and communication; social behaviour; emotional
stability; developed from original 136-item 170
Nottingham Health Profile (NHP) 171 45 experience: energy, pain, emotional reactions, sleep, social isolation, physical mobility;
daily life: employment, household work, relationships, home life, sex, hobbies,
holidays
Perceived quality of life (PQOL) 172 11 satisfaction with: bodily health; ability to think/remember; happiness; contact with
family and friends; contribution to the community; activities outside work; whether
income meets needs; respect from others; meaning and purpose of life; working/
not working/retirement; each scored on 0–100 scale

60 S C O P E O F C R I T I C A L C A R E

most commonly used and validated instrument in the Physical activity associated with cardiac or pulmonary
literature, including with a variety of critically ill patient dysfunction may be assessed using perceived breathless-
groups (e.g. general ICU, ARDS, trauma and septic shock). ness (dyspnoea) during exercise by the modified Borg
50
A recent comparison of two related instruments demon- scale, ranging from 0 (no dyspnoea) to 10+ (maximal).
strated that the 15D was more sensitive to clinically The Borg scale is commonly used with other physical
important differences in health status than EQ-5D in a activity instruments, e.g. the six-minute walk test
critical care cohort. 46 (6MWT). 51
MEASURES OF PHYSICAL FUNCTION MEASURES OF PSYCHOLOGICAL FUNCTION
FOLLOWING A CRITICAL ILLNESS AFTER A CRITICAL ILLNESS
A variety of instruments have been developed to examine The recovery process and trajectory for survivors of a criti-
the physical capacity of individuals, usually focusing on cal illness remains an important but under-researched
functional status ranging from independent to depen- area. 18,52 Exploration of the impact of the intensive care
dent. Table 4.2 describes some common instruments experience, including ongoing stress 53-56 and memories
used with individuals after an acute or critical illness. for the patient, 16,57-59 is now emerging in the literature as
Many other instruments exist for specific clinical cohorts, an important area of research and practice. Instruments
47
including Katz’s ADL index, the Karnofsky performance that assess mental function after a critical illness focus on
48
49
status, and the instrumental activities of daily living, psychological constructs, including anxiety, avoidance,
but these have not been used commonly with survivors depression and fear (see Table 4.3). Other instruments
of a critical illness. are also available to examine post-traumatic stress


TABLE 4.2 Common measures of physical function following a critical illness

Instrument Measurement Score range/comments
St George’s Respiratory COPD-specific items assessing three Item responses have empirical weights; higher scores indicate
173
Questionnaire (SGRQ), domains: symptoms (7 items), activity poorer health; used with patients with chronic lung disease,
(SGRQ-C) 174 (2 multi-part items), impacts (5 multi-part including ARDS
items)
Six-minute walk test (6MWT) 51 Walk distance, reflects functional capacity in Assesses walk function in patients with moderate heart failure,
respiratory or cardiac diseases ARDS
Barthel Index (BI) 175-177 10 items of functional status (Activities of Dependence: total = 0–4; severe = 5–12; moderate = 13–18;
Daily Living [ADLs]) slight = 19; independent = 20
Functional Independence Severity of disability in inpatient 18 activities of daily living in two themes: motor (13 items),
Measure (FIM) 178 rehabilitation settings cognitive (5 items); 7-point ordinal scales; score range
18–126 (fully dependent–functional independence)
Timed Up and Go (TUG) 179 Functional ability to stand from sitting in a ≤10 seconds = normal; ≤20 seconds = good mobility,
chair, walk 3 m at regular pace and return independent, can go out alone; 21–30 seconds = requires
to sit in the chair supervision/walk aid
Shuttle walk test (SWT) 180 10 m shuttle walk with pre-recorded audio Participant keeps pace with audio sounds; 12 levels of speed
prompts to complete a shuttle turn (0.5–2.37 m/second)
ARDS = Adult Respiratory Distress Syndrome




TABLE 4.3 Examples of common measures of psychological function after critical illness

Instrument Measurement Score range
Impact of event scale (IES); IES-R 182 15-item; assesses levels of post-traumatic distress; frequency of thoughts over past 7 days; 0 = no
181
two subscales: intrusive thoughts, avoidance thoughts; 5 = often; higher scores indicate
behaviours; revised form (IES-R) adds hyper- greater distress: scores ≥26 (combined intrusion
arousal subscale (7 items) 182 and avoidance) are significant
Hospital anxiety and depression 14 items; 4-point scale; measures mood disorders combined score ≥11 indicates a clinical disorder
scale (HADS) 89 in non-psychiatric patients; focuses on
psychological rather than physical symptoms of
anxiety and depression
Center for Epidemiologic Studies– 20-item self-report scale assessing frequency and score range 0–60; higher scores reflect increased
Depression Scale (CES–D) 183 severity of depressive symptoms experienced in symptoms and severity
the previous week

Recovery and Rehabilitation 61

60
symptoms. Constructs that relate to an individual high, specificity (ability to correctly identify all patients
during a critical illness episode also include without the condition) is less easy to determine, and
14
agitation, and confusion/delirium (discussed further in therefore the incidence of psychological distress may be
Chapter 7). over-stated. This makes estimation difficult and is one of
the challenges in establishing the actual magnitude of
Assessment for ongoing neuro-cognitive dysfunc-
tions 17,61,62 is recommended for some survivors, with the psychological distress after a critical illness. Other chal-
beginning of research on cognitive rehabilitation for lenges include the recruitment of different cohorts or
survivors of a critical illness evident. 15,17-19,63 Cognitive subgroups of patients (e.g. patients with Adult Respira-
87
90
executive functioning includes attention, planning, tory Distress Syndrome or Acute Lung Injury ). Varia-
problem-solving and multi-tasking. 64 tions in the international provision of ICU services also
means that differences may exist in case mix in the areas
of illness severity, planned or unplanned admissions,
ages and reasons for admission. For example, in a sample
PSYCHOLOGICAL RECOVERY of studies mean age ranged from 40 –59 years, mean
90
91
92
83
APACHE II scores ranged from 15 –24.9, and median
Psychological responses to a critical illness and patients’ 83 87
memories of experiences during an ICU admission have length of ICU stay from 3.7 –34 days.
been explored using quantitative 57,65-69 and/or qualitative
approaches. 70,71 Some survivors reported increased anxiety, ANXIETY AND DEPRESSION
32
including transfer anxiety (discharge from ICU); depres- Reported prevalence of anxiety and depression after ICU
13
sion; post-traumatic stress; 14,72-74 hallucinations; 58,75,76 discharge varies depending upon the questionnaire and
77
and continuing cognitive dysfunction. A range of ‘cut-off’ scores used, and the research design (see Table
memories and experiences were also noted after ICU 4.4). For example, one study of an intensive care follow-up
78
transfer and hospital discharge, 58,70,79 including power- clinic reported anxiety prevalence of 7% three months
lessness, reality–unreality, reactions and acceptance, and after discharge; much less than a similar study where
83
comfort–discomfort. 85
anxiety was 18% one year after discharge. Both studies
For some patients, recovery from a critical illness results used the HADS with scores of ≥11 to indicate an anxiety
in short- and long-term psychological dysfunction (e.g. or depressive problem. Prevalence of depression in these
83
85
anxiety, depression and posttraumatic stress symp- studies was more equivalent, 10% and 11%. Table 4.4
toms). 8,80 Our understanding of these sequelae has provides a summary of studies reporting the prevalence
improved over the last decade in part due to increased of anxiety and depression. These differences may be
research activity and evaluations of intensive care explained by differences in case mix or timing of
follow-up clinics in the UK (discussed in a later section). assessment.
Importantly, negative psychological consequences of Patients often exhibit high levels of distress at time of
intensive care can result in poorer health status and per- hospital discharge and these tend to reduce in the first
ceptions of HRQOL. 81
year after discharge. 85,90 However the episodic timing of
Assessment of psychological outcomes has mainly relied assessments may not fully capture patterns of anxiety and
on self-report questionnaires administered via either a depression, and establish whether full resolution is
postal survey or a structured interview format. These achieved. For example, in patients with ARDS, levels of
screening, rather than diagnostic, strategies enable iden- depression increased from 16% at 1 year after discharge
93
tification of individuals at risk of developing a significant to 23% at 2 years. This may reflect prolonged recovery
clinical problem. A number of standardised question- in general for this subgroup of patients, who tend to be
naires have demonstrated reliability and validity in this among the most critically ill patients, with a mean ICU
patient group, but the use of different questionnaires stay of 34 days noted. A rise in depression scores may
makes it difficult to generalise findings. Studies that therefore be a reflection of that prolonged physical
assessed anxiety and depression used the Hospital Anxiety recovery.
and Depression Scale (HADS), 57,82-86 Beck Anxiety Inven- What is emerging from the literature is that certain patient
87
68
tory, State Trait Anxiety Inventory (STAI), and the Beck demographic and clinical characteristics predict subse-
Depression Inventory. 68,87 Posttraumatic stress has been quent anxiety and depression, although not consistently.
assessed using the Impact of Event Scale (IES), 57,68,84,85 Women tend to be more anxious than men 83,85 and
Post-Traumatic Stress Syndrome 10-Questions Inventory younger patients more anxious than older patients.
85
74
73
(PTSS-10), Davidson Trauma Scale, and the Experience Other consequences of being in intensive care such as
after Treatment in Intensive Care 7 (ETIC-7) item scale. 88
neuropsychological impairment can also predict signifi-
92
These instruments often include ‘cut-off’ or ‘threshold’ cantly higher depression scores. Sicker patients, those
scores that enable screening for the presence or severity with a longer length of ICU stay, and also a longer dura-
of a disorder. For example, a score of 8–10 on either sub- tion of sedation and mechanical ventilation are more
82
scale of the HADS indicates possible presence of a disor- likely to have measurable depression. This is perhaps
der, while a score of 11 or above indicates probable not surprising as patients who are in intensive care longer
89
presence of such a condition. One limitation of these tend to have more prolonged hospital stay and recovery
self-report measures is that while sensitivity (ability to period. What is also evident in the emerging literature
correctly identify all patients with the condition) can be is the effect of patients’ subjective intensive care

62 S C O P E O F C R I T I C A L C A R E



TABLE 4.4 Summary of studies examining anxiety and depression in survivors of a critical illness

First
a
author/ Acuity /ICU Instrument/
Country Design n/Male Cohort LOS days Age cut-off score Main findings
b
Eddleston Cross-sectional 143/52% Follow-up clinic 15/3.7 51 HADS ≥11 7% met the criteria for anxiety,
(2000) / 3 months and 3% depression
83
UK post- Females more likely to have
discharge higher anxiety scores
c
Nelson Cross-sectional, 24/58% 19 months 58 /27 40 GDS /16 Positive correlation r = 0.30
d
(2000) / postal survey (mean) after between depression scores
90
UK acute lung and days of sedation; 69% of
injury patients not depressed prior
to ICU scored >16
Scragg Cross-sectional 80/52% Survival from –/– 57 HADS >8 43% scored above 8 for anxiety
(2001) / postal survey ICU over 2 and 30% for depression.
88
UK years
Jones Cohort 30/67% 2 and 8 weeks 17/8 57 HADS ≥11 Patients with no factual but
57
(2001) / after ICU some delusional memories
UK discharge were more likely to be
anxious and depressed at
2 weeks
Jones RCT 116/61% General ICU 17/14 58 HADS >11 No statistically significant
91
(2003) / patients – 3 differences between the two
UK hospitals; 8 groups; there was a trend to
weeks and 6 reduced depression scores
months after for those with scores >11 at
discharge 8 weeks
Jackson Prospective 34/53% Medical and 24.9/– 53.2 GDS-SF ≥6 Patients with
92
(2003) / cohort coronary ICU; neuropsychological
USA 6 month impairment were more like to
follow-up score above the threshold at
6 months (36% v 17%).
Hopkins Prospective 66/50% ARDS; 12 18.1/34 46 BDI >30 9% severe levels of anxiety and
87
(2004) / longitudinal month BAI >30 6% severe levels of depression
USA follow-up at 12 months
Hopkins 2 year Anxiety and depression
(2005) / follow-up persisted up to 2 years with
93
USA 23% reporting moderate to
severe levels
Rattray Prospective 80/64% General ICU; 17.7/4.9 54.7 HADS ≥11 Anxiety and depression
85
(2005) / longitudinal Hosp significantly reduced between
UK discharge, 6 6 & 12 months; 18%
& 12 months demonstrated probable
anxiety, 11% probable
depression
Sukantarat Prospective 51/43% ICU patients ≥3 15.3/16.9 57.4 HADS: anxiety 24% had anxiety scores
184
(2007) / days; 3 & 9 ≥10 ≥10 at both 3 & 9 months
UK months HADS: 35% had depression scores
depression ≥8 at 3 months and 45% at six
≥8 months
Dowdy Prospective 161/55% Acute Lung ≤20 = 80%/ 49 HADS ≥11 11% scored above threshold at
(2009) / cohort Injury; 6 ≤10 = 51% 6 months
82
USA months
Myhren Cross-sectional 255/63% 4–6 weeks SAPS 37/12 48 HADS ≥11 Mean anxiety (5.6 v 4.2) and
e
84
(2009) / post-ICU depression (4.8 v 3.5) scores
Norway discharge higher than general
population norms
Myhren Longitudinal As above and 3 Unemployment and optimism
(2010) 86 & 12 months were predictors of anxiety
scores; surgery and optimism
predicted depression
a APACHE II score, Hospital Anxiety and Depression Scale, Geriatric Depression Scale – Short Form, APACHE III score, Simplified Acute Physiology Score
e
b
d
c

Recovery and Rehabilitation 63

experiences. These experiences tend to be reported as self-report measures, different research designs, varied
unpleasant memories of being in ICU 16,57-59,84,85 and are patient casemix and international variations in the
discussed later in this chapter. delivery of intensive care. These variations have resulted
in overestimation of the prevalence of PTSD and post-
Depression is also associated with other aspects of recov- 100
ery and in particular HRQOL. Depressed patients tend to traumatic stress symptoms (PTSS), although note
rate their HRQOL as poorer than those who are not. 85,93 that patients with significant PTSS may be less likely to
However what is less clear is the direction of this relation- participate in research studies. While PTSD should be
12
ship; it could be that patients with a poorer HRQOL tend diagnosed through a structured clinical interview,
to be depressed rather than depression leading to percep- few studies use this approach. One small study compared
tions of poorer HRQOL. Patients who have psychological the prevalence of PTSD in patients who had daily
problems prior to intensive care are likely to develop sedation withdrawal versus those who did not; 6/19
these after discharge. Although assessment of pre-ICU patients who did not receive daily sedation withdrawal
status is difficult, in some cases this information can be were diagnosed with PTSD, while 0/13 were diagnosed
68
obtained from relatives or caregivers. from the intervention group. The small sample size was
a limitation but nonetheless these were important
POSTTRAUMATIC STRESS findings.

In recent years there has been increasing interest in the Patients may have significant PTSS without developing
development of posttraumatic stress reactions such as PTSD and it is mainly these symptoms that are assessed
Posttraumatic Stress Disorder (PTSD) as a response to using the self-report measures. Reported prevalence of a
critical illness, 94,95 and there is increasing recognition of significant posttraumatic stress reaction or PTSD is 14–
74
these symptoms as a problem for some intensive care 27%. As for anxiety and depression, there are certain
survivors. 14,72 Individuals do not perceive or respond to patient and clinical characteristics that can predict likeli-
101
traumatic or life-threatening events in the same way, but hood of a posttraumatic stress reaction. Trauma and
96
there are commonalities including that events are often younger patients tend to have higher scores on measures
74,85,88
perceived as a threat to life, are uncontrollable and unpre- of posttraumatic stress. Aspects of an intensive care
dictable and that they are beyond the usual human experience are associated also with a posttraumatic stress
97
85,90
experience. Many symptoms of posttraumatic stress that reaction. Patients with a longer ICU stay, longer dura-
98
90
patients experience in the initial days after intensive care tion of sedation and/or neuromuscular blockade, and
74
discharge may be considered a normal reaction. There- mechanical ventilation are more likely to report
fore practitioners need to clearly separate the normal posttraumatic stress symptoms. Patients who have daily
from the abnormal response; this is achieved by assessing sedative interruption had lower scores on the Impact of
68
the severity, duration of symptoms, and their effect on an Event Scale. Importantly, daily sedative interruption or
individual’s life. PTSD should not be diagnosed until at withdrawal, or titration of sedation is becoming more
least one month after the event, and until the symptoms common in practice and therefore requires further
have been present for one month. Symptoms commonly research. Certain subgroups of patients appear to have a
81
cause problems in relation to work, social or other impor- higher prevalence of PTSD (e.g. ARDS patients ), and
99
tant activities; this is important to consider when devel- PTSD can often endure for many years.
oping critical care follow-up services. Importantly, PTSD
symptoms may be reactivated after some time, and being MEMORIES AND PERCEPTIONS
in ICU may serve as a catalyst for some patients, e.g. reliv- Interestingly, illness severity does not consistently predict
ing a war event. e.g.58 a PTSS reaction, 73,85 but rather perceptions of the inten-
sive care experience. This is one of the unique features of
Signs of posttraumatic symptomatology include three being in intensive care; patients have little recall for
symptom areas: intrusive thoughts, avoidance behav- factual events and often report large gaps where they
iours and hyper-arousal symptoms. Individuals can remember very little about their critical illness. Patients’
re-experience a traumatic event through unwanted accounts often include disturbing recollections with
thoughts, often in the form of ‘flashbacks’ and/or ‘night- memories of ‘odd perceptual experiences’, 54,102 ‘night-
mares’. Individuals experiencing these thoughts often mares’ or ‘hallucinations’. 57,58 While not all patients expe-
develop avoidant behaviours in the belief this action will rience these, those who do so tend to report memories
reduce the intrusive thoughts. Avoidant behaviours for that are persecutory in nature, are often associated with
103
intensive care patients can range from simply avoiding feelings of being elsewhere, reliving a previous life
102
television programs about hospitals, not talking about event, or fighting for survival. These memories often
104
102
their ICU experience or, more seriously, non-attendance seemed ‘real’ and were distressing to patients at the time,
at a follow-up clinic or other hospital out-patient appoint- and may be recalled in detail some months afterwards.
58
ments. Hyper-arousal behaviours include difficulties in Having delusional rather than factual memories is more
concentrating or falling asleep. Assessment of posttrau- likely to result in distress; 56,57,85,105 and lack of memory for
matic stress in survivors of a critical illness should examine factual events may result in longer-term psychological
all three symptom areas.
57
problems, with the important element being the content
As with other psychological symptoms such as anxiety of the ICU memories rather than the number of memo-
and depression, it has been difficult to establish the pre- ries. Table 4.5 summarises studies exploring posttrau-
valence of PTSD after intensive care because of the use of matic stress after ICU.

64 S C O P E O F C R I T I C A L C A R E



TABLE 4.5 Summary of studies examining Posttraumatic Stress Symptoms (PTSS) in survivors of a critical care

First author/ Instrument/
a
Country Design n/Male Cohort Acuity /ICU LOS Age cut-off score Main findings
Perrins Prospective 38/– General ICU; 6 weeks, —/6 49 IES/- Avoidance and
101
(1998) /UK 6 & 12 months intrusion scores
post-ICU discharge reduced at 12
months; scores
associated with
patients’ recollection
of ICU – those with
no recall had higher
scores
Schelling Retrospective 80/51% ARDS; patients 22/31 36 PTSS > 35 25% scored above
(1998) / cross- discharged over 10 cut-off score;
73
Germany sectional year period symptoms
associated with the
number of traumatic
memories of ICU
Nelson Cross- 24/58% 19 months (mean) after 58/27 40 7 item Significant correlation
(2000) /UK sectional acute lung injury questionnaire with days of
90
sedation and days of
neuromuscular
blockade and PTSS
scores
Scragg Cross- 80/52% Admitted to ICU over -/- 57 IES ≥ 20 12% high levels of
88
(2001) /UK sectional previous 2 years avoidance, 8% high
levels of intrusive
thoughts. Younger
patients had higher
IES scores
Jones (2001) / Cohort study 30/66% General ICU; 2 & 17/8 57 IES Patients with no factual
57
UK 8 weeks but who reported
delusional memories
had higher IES
scores at 8 weeks
Jones (2003) / RCT 116/61% General ICU patients – 17/14 58 IES >19 Patients who received
91
UK 3 hospitals; 8 weeks 6-week rehabilitation
and 6 months after program had lower
discharge IES scores at 8 weeks
but not 6 months;
51% scored >19 at
6 months
Kress (2003) / RCT 32/58% Medical ICU; 11–14 Control 18.4/12.8; 48 IES; structured Evaluated the effect of
68
USA months after hospital Intervention clinical daily sedation
discharge 16.2/6.9 interview withdrawal; patients
in the intervention
group reported
lower IES scores
(not statistically
significant); 6
patients in the
control group were
diagnosed with
PTSD compared with
no patient in the
intervention group
Cuthbertson Prospective 78/72% General ICU 3 months 18/5.6 58 DTS ≥27 – high 22% demonstrated
(2004) /UK cohort after discharge level high level of PTS
74
≥40 PTSD symptoms and 12%
confirmed PTSD

Recovery and Rehabilitation 65



TABLE 4.5, Continued

First author/ Instrument/
a
Country Design n/Male Cohort Acuity /ICU LOS Age cut-off score Main findings
Kapfhammer Cross- 46/52% ARDS; median 8 years 22.5/— 36 PTSS-10 >35 24% of patients
(2004) / sectional after treatment diagnosed with
81
Germany PTSD; a further 17%
had sub-threshold
PTSD; those with
PTSD reported a
poorer HRQOL
Rattray Prospective 80/64% General ICU; hospital 17.7/4.9 55 IES ≥20 12% reported severe
(2005) /UK longitudinal discharge, 6 & avoidant behaviour,
85
12 months 18% severe intrusive
thoughts at 12
months; scores did
not reduce over 12
months and were
associated with
reported ICU
memories and age
Sukantarat Prospective 51/43% In ICU ≥3 days; 3 & 15.3/16.9 57.4 IES: intrusion Intrusion in 24% at 3
(2007) /UK 9 months after ≥21; months and 20%
184
ICU discharge avoidance at 9 months;
≥18 avoidance in 36% at
3 months and 38%
at 9 months
Wallen Predictive 100/ ≥24 hours ICU LOS; 13.0/2.4 63 IES-R ≥33 Mean IES-R=17.8; 13%
185
(2008) / cohort 68% medical/surgical ICU; scored higher than
Australia 1 month after cut-off score; those
discharge ≤ 65 years were 5.6
times more likely to
report PTSS
Weinert Prospective 149/52% Medical and Surgical –/– 54 PTSD PTSD prevalence at 2
105
(2008) / ICUs; 6 positive months was 17%
USA 2 & 6 months responses and this had
across 3 reduced to 15% by 6
domains. months; patients
who reported
delirious memories
had higher PTSD
scores
Myhren Cross- 255/63% Medical/surgical ICUs SAPS 37/12 days 48 IES ≥ 35 25% above threshold
84
(2009) / sectional and CCU; 4–6 weeks
Norway post-discharge
Myhren Longitudinal 3 & 12 months 27% above threshold
86
(2010) / at 12 months; no
Norway differences in scores
across time; high
education level,
optimism trait,
factual recall,
memory of pain
were independent
predictors of PTSS

66 S C O P E O F C R I T I C A L C A R E

INTERVENTIONS TO IMPROVE hospital discharge. 111,115,116 Table 4.6 outlines recent studies
PSYCHOLOGICAL RECOVERY examining physical activity and mobility strategies for
Although there is now strong empirical evidence that patients in ICU.
some patients experience significant psychological dys-
functions after a critical illness, it is less clear how to treat MOBILITY AND WALKING
these symptoms. Systematic follow-up services may offer Testing of ‘early’ activity for ICU patients relates to after
appropriate assessment support during recovery for indi- clinical stabilisation is evident, and includes those still
viduals identified with psychological disturbances. Inten- intubated. 110,112 Factors to ensure patient safety during
sive care follow-up clinics where patients have the mobilisation have been identified, including confirming
opportunity to discuss their intensive care experiences that a patient has sufficient cardiovascular and respiratory
117
and receive information about what had happened to reserve and cognitive function, and subsequently
them could be a useful intervention, although there are tested. 111,118 Potential barriers to mobilisation during
53
currently no empirical data to support this, and further mechanical ventilation (e.g. acute lung injury, vasoactive
research work is required. infusions) have also been examined. 112
Patient diaries were also thought to be important in pro- Physiotherapy recommendations for physical de-
viding missing pieces of information that might help a conditioning include development of ‘exercise prescrip-
119
patient make sense of their critical illness experience. A tions’ and ‘mobilising plans’. Activities range from
diary approach has been adopted in a number of Euro- passive stretching and range of motion exercises for limbs
pean ICUs, 106,107 and while there has been some variation and joints, positioning, resistive muscle training to
in how the diaries were compiled and then viewed by a aerobic training and muscle strengthening and ambula-
patient, there is emerging evidence that supports their tion. 119,120 Specific mobility activities include:
108
use. Note however that not all patients may wish to be ● in-bed (range of motion, roll, bridge, sitting on edge
reminded of their ICU experience; this is especially the of bed)
case for patients who demonstrate avoidant behaviours. ● standing at side of bed
Others may wish not to be reminded of being critically ● transfer to and from bed to chair
53
ill but wish to concentrate on recovery. Further research ● marching on the spot
that incorporates these issues during assessment of post- ● walking. 117
traumatic stress symptoms will further establish the effec-
tiveness of diary use (see Research Vignette later in this Patient support for each activity ranges from assistance
chapter). with 1–2 staff through to independence under supervi-
121
sion. Rehabilitation devices can also include a tilt-table,
The recent UK NICE guidelines emphasised regular neuromuscular electrical stimulation (NMES), bedside
109
assessment of patient recovery including psychological cycle ergometry and adapted walking frames. 122 Inspira-
recovery. Assessment periods include during intensive tory muscle training (IMT) has been used for weakness
care, ward-based care, before discharge home or commu- associated with prolonged mechanical ventilation, 123
nity care and 2–3 months after ICU discharge, with the using resistance and threshold-training devices. There is
use of existing referral pathways and stepped care models however no current strong evidence 124 supporting an
to treat identified psychological dysfunctions. These ser- independent benefit of IMT, but it can be used as adjunc-
vices are usually well established and allow patients to be tive therapy. 125,126
treated by appropriately qualified practitioners. The role
of critical care practitioners may therefore be to establish A survey of practices in Australian ICUs noted that 94%
the causes of psychological disturbances associated with of physiotherapists prescribed exercise frequently for
critical illness, identifying at-risk patients through system- both ventilated and non-ventilated patients, but practices
atic and standardised screening activities, closely moni- did vary widely and no validated functional outcome
toring identified patients and referring to appropriate measures were used. 127 As noted earlier, a culture of
specialties where appropriate, to optimise their recovery patient wakefulness and early in-ICU activity and mobil-
trajectory while not introducing any further harm. ity is advocated but challenged by the status quo of
work practices and health professional role delinea-
REHABILITATION AND tions. 113,118,128-130 A re-engineering of work processes and
practices to promote patient activity is therefore required
MOBILITY IN ICU to ensure optimal outcomes for survivors of a critical
illness.
Interventions to minimise ICU-AW, particularly in rela-
tion to muscle de-conditioning from disuse (e.g. seda- Further development and testing of candidate interven-
tion; bed-rest) have recently focused on active exercises tions also remain, particularly in terms of patient selec-
and mobility, even while patients are intubated and ven- tion, when to commence, and the duration, intensity and
26
tilated. Early studies of in-ICU mobility have demon- frequency of the rehabilitation interventions. Activities
131
strated safe and feasible interventions, 110-112 although this may also be adopted and adapted from other established
focus requires a cultural shift with a multi-disciplinary rehabilitation programs in pulmonary stroke cohorts.
128
team approach and changes in care processes. 26,113,114 Technological devices, such as virtual reality rehabilita-
In-ICU rehabilitation has also reduced ICU and hospital tion 132 may also prove to be beneficial in this cohort with
lengths of stay and improved physical function at further development and testing.

TABLE 4.6 Summary of recent studies of in-ICU activity and mobility

First author/
country Design n/Age Cohort Intervention Measures Main findings
Zanotti RCT 24/65 Bed-bound active limb mobilisation ± Muscle strength 2.2 vs 1.3 (MRC scale)
2003 /Italy MV ARF electrical stimulation, Bed to chair transfer 10.8 vs 14.3 days
186
(49 days ≤30 minutes 2×/day x 5
median) days/week × 4 weeks
Chiang RCT 33/77 Prolonged MV ROM, functional dynamometer 4.5 vs 0.9 kg b
187
2006 / (49 days retraining, 5×/week BI 35 vs 0
a
Taiwan median) × 6 weeks FIM 49 vs 26
Ventilator-free 6 vs 0 hours
110
Bailey 2007 / Cohort 103/63 Prolonged MV Sit on bed, sit in chair, Walk 30m pre-RICU 70% of survivors reached
USA (19 days ambulate ± assistance discharge goal; 65m mean distance
median) 2×/day Activity-related safety <1%
events
c
Morris 2008 / Cohort 330/55 ARF within 48 ‘Mobility team’ > 20 min ICU LOS 5.5 vs 6.9 days
111
USA hours of MV 3x/day Out of bed 11 vs 5 days
Hospital LOS 14.5 vs 11.2 days
115
Burtin 2009 / RCT 90/57 Prolonged ICU Daily exercise; 20 minutes 6MWD, hospital D/C 196 vs 143 metres*
Belgium (expected with bedside cycle Isometric quadriceps 2.37 vs 2.03 Newton (n.s.)
d
12 day LOS) ergometer from Day 5, SF-36 PF 21 vs 15 (P < 0.01)*
5 days/week ICU LOS 25 vs 24 days (n.s.)
Hospital LOS 36 vs 40 days (n.s.)
Schweickert / 2-site RCT 104/56 Daily Exercise and mobilisation independent function Intervention: 59%
116
e
USA Interruption (PT & OT) for stable and at hospital discharge Control: 35% (P = 0.02)*
of Sedation awake patients; activity ventilator-free days 23.5 vs 21.1
based on patient ICU LOS 5.9 vs 7.9 days (n.s.)
stability and tolerance hosp. LOS 13.5 vs 12.9 (n.s.)
MRC/handgrip 52 vs 48/29 vs 35 kg (n.s.)
Skinner Pilot, testing 12/57 General ICU Prescribed exercise PFIT battery f Inter-rater reliability 0.99;
2009 / of training based on PFIT responsive
188
Australia outcome findings, once/day while
measure ventilated, 6 days/week
Bourdin Cohort 20/68 ≥7 days ICU Protocol of chair sitting, Chair 56%
121
2010 / ≥2 days MV tilt-table, walking Tilt-up ± arm support 33%
France activities; 33% during Walking 11%
MV Adverse events good tolerance; feasible &
safe – 3% (no harm)
Needham Before/after 57/52 ≥2 days MV Structured QI model, Benzodiazepine use 50% vs 25% P = 0.02*
2010 /USA QI project multi-disciplinary team, Functional mobility 56% vs 78% P = 0.03*
130
new PT and OT referral ICU LOS 17.2 vs 14.1 days P = 0.03*
and sedation reduction Hospital LOS 23.3 vs 21.0 days P = 0.55
guidelines
Pohlman Intervention 49/58 <3 days MV Sedation interruption, PT/ Feasibility of early PT Intubated participants sat
112
2010 /USA arm of with OT rehabilitation and OT (1.5 days at edge of bed in 69%,
g
RCT expected protocol , sessions median post- stood in 33% and
further MV 25–30 minutes intubation) ambulated in 15% of
sessions
Williams 2-phase 18 & 20/ Impaired 1: regular chair, with Seating interface Lower excessive
h
2011 / cross-over 66 & mobility overlay, alternative chair pressures/pressure pressures in alternative
189
Aust. 62 compared maps chair, but lack of utility
2: new surface compared in ICU
to regular 93% of participants had
fewer excessive
pressures with new
surface (P < 0.01)
ADLs = activities of daily living, ARF = acute respiratory failure, BI = Barthel Index, D/C = discharge, FIM = Functional Independence Measure, MRC = Medical Research
Council scale, LOS = length of Stay, n.s. = no statistically significant differences between groups, MV = mechanical ventilation, OT = occupational therapy, PT =
physical therapy, QI = Quality improvement project, RCT = randomised controlled trial, RICU = Respiratory Intensive Care Unit, ROM = range of motion, 6MWD = 6
minute walk distance
a turning side to side in bed, transfers to and from bed and chair, standing
b shoulder flexors
c Registered Nurse, Nursing Assistant, Physical Therapist team; passive ROM, turning, active resistance, sitting, transfer
d passive or active cycling, 6 levels of increasing resistance; sedated patients received passive cycling at 20 cycles/minute
e daily passive ROM for unresponsive; after Daily Interruption of Sedation, assisted and independent active ROM supine, bed mobility (transferring to upright sitting
and balance), and ADLs, transfer training (sit-to stand from bed to chair), pre-gait exercises, walking
f sit (chair) to stand (0–3 assistants), march on spot (time, steps/minute), bilateral shoulder flexion (time, reps), muscle strength (0–5 MRC)
g passive ROM for unresponsive; assisted and independent active ROM supine, bed mobility (lateral rolling, transferring to upright sitting), balance, ADLs, transfer
training, walking
h excessive pressure = 200 mmHg over bony prominences; to be <2 hours in young, healthy volunteers
*statistically significant difference between groups (P < 0.05)

68 S C O P E O F C R I T I C A L C A R E

WARD-BASED POST-ICU RECOVERY optimal duration, intensity and frequency of interven-
tions is not yet clear. 131
Follow-up services for survivors of a critical illness in
Australia and New Zealand have occurred sporadically in RECOVERY AFTER HOSPITAL
individual units with interested clinician teams, 133 but
there is currently no widespread systematic approach to DISCHARGE
recovery and rehabilitation and the management of phy- Of patients who survive their critical illness to hospital
sical, psychological or cognitive dysfunctions beyond discharge, 5% will die within 12 months, and their risk of
clinical stability and deterioration with ICU Liaison ser- death is 2.9 times higher than for the general population.
2
vices 134,135 or Medical Emergency Teams (MET). 136 Functional recovery can be delayed in some individuals
30
Commencement or continuation of rehabilitation activi- for 6–12 months 3-5,145 or longer. In a recent study in
ties in the general wards after discharge from ICU high- Norway, only half of 194 patients had returned to work or
lights a potentially different set of challenges, particularly study one year after surviving their critical illness. 145
in terms of physiotherapy resources, involvement of other There is however only limited research and mixed study
medical teams, compliance to a prescribed plan. While findings identifying specific interventions during the
some cohorts of critically ill patients (e.g. pulmonary, post-hospital period that may improve a patient’s recov-
cardiac, stroke, brain injury) have defined rehabilitation ery trajectory and health outcomes. Most work has
pathways, 128 patients with other clinical presentations involved practice evaluations or studies of outpatient
may not be routinely prescribed a rehabilitation plan or ‘ICU follow-up’ clinics, e.g.91,146,147 while there is some
be referred to a rehabilitation specialist. beginning work exploring home-based programs. e.g.148,158
For Australian and New Zealand patients who survive to
ICU discharge, approximately 3% will die prior to hospi- ICU FOLLOW-UP CLINICS
tal discharge. 137 Some work in Europe on prognosis post-
ICU discharge using the 4-point Sabadell Score (0 = good Systematic follow-up for survivors of a critical illness after
prognosis; 1 = long-term poor prognosis; 2 = short-term hospital discharge emerged in the UK in the early 1990s,
poor prognosis; 3 = expected hospital death) 138 demon- after a number of government reviews on the cost and
strated that subjective intensivist assessment was able to effectiveness of critical care services highlighted: the need
139
predict the risk of patient mortality, and conversely to evaluate longer-term patient outcomes, in particular
those patients potentially suitable for rehabilitation. quality of life; 149 and recognised that patients had sequelae
that were best understood and managed by ICU clini-
Impairment in functional ability can be significant for cians. In 2000, the UK Department of Health published
some patients after ICU-discharge. In a small Dutch a comprehensive review of critical care services. With
observational study (n = 69) of patients who had mechan- emerging albeit limited evidence of the benefits of an ICU
ical ventilation of 48 hours of more, over 75% of the follow-up clinic, the review recommended the provision
sample were totally or severely dependent for activities of of follow-up services for those patients expected to
daily living (Barthel Index 0–12) 4 days after ICU- benefit. Importantly, this review also recommended
150
discharge. 140 Close monitoring and early rehabilitation collection of patient recovery and outcome data; this has
during this period was therefore recommended. been facilitated through follow-up clinics. The review did
Specific ward-based rehabilitation interventions follow- not however indicate how these services should be deliv-
ing ICU discharge are beginning to be investigated. Some ered or funded. The emerging pattern in the UK has
exploratory work in the UK implemented a generic reha- therefore been to invite patients to a follow-up clinic.
bilitation assistant to support enhanced physiotherapy The first intensive care follow-up clinics were established
and nutritional rehabilitation in collaboration with ward- in the UK in the early 1990s, driven by a few interested
151
based staff. 141,142 Feasibility of the role and process was and committed intensive care clinicians. From this early
established, and further work in a larger sample will test beginning the number of clinics has increased; a recent
the efficacy of the intervention. 142
survey noted at least 80 follow-up clinics from approxi-
151
The benefits of physical exercise training for patients with mately 300 ICUs throughout the UK. A number of
COPD was affirmed in a recent review, with recommen- decisions are required when implementing a follow-up
dations focused on maintenance of health behaviour clinic, as different models have evolved as nurse-led,
change, 143 and these guidelines could be applied to some doctor-led or a combination of both; more than half in
cohorts of critically ill survivors. Identification of the the UK are currently nurse-led. Some services include
151
most effective level of intervention however remains input from allied health professionals and psychologists,
elusive. One Australian study of acute medical patients although this multi-disciplinary approach is less common.
(not after critical illness) noted that individually tailored This may be a reflection of resource implications but is
physical exercise (20–30 minutes twice daily, 5 days per in keeping with the general development of nurse-led
week) in hospital was not sufficient to influence func- services within the UK. Many clinics restrict patients
tional activity at discharge. 144 Further research is therefore invited to return to those with an ICU length of stay of
required to test specific interventions during the post-ICU at least 3 or 4 days. This decision is often based upon
hospital period aimed at improving the recovery trajec- resources rather than evidence, as patients who have a
tory and health outcomes for patients with limited physi- shorter stay may also have subsequent physical and psy-
cal function. As noted with in-ICU rehabilitation, the chological problems. 146

Recovery and Rehabilitation 69



BOX 4.1 Purpose of an intensive care TABLE 4.7 Sample clinic assessment tool
follow-up service
Subject area Rationale
● Review and assess patient progress
● Early identification of problems and refer to appropriate General health Assessed on a linear analogue or forced
choice response to elicit a patient’s
specialties where necessary subjective account of how they view
● Coordinate care their general health and how it has
● Support a rehabilitation program changed since critical illness
● Discuss the intensive care experience and offer patient the Medications Review of medications commenced during
opportunity to comment on care the critical illness and continued
● Offer patient opportunity to visit the ICU post-discharge, with advice provided to
146
● Provide a forum for relatives to ask questions the patient’s General Practitioner
● Use information to inform delivery of intensive care Movement and Assess mobility problems, often due to
mobility, continuing fatigue and weakness, but
household also perhaps joint problems; 190,191
management identify impact on daily activities 109,192,193
and joints
Common practice is to invite patients to attend a first Breathing and Breathlessness is common after critical
192
clinic appointment approximately 2–3 months after dis- tracheostomy illness and there are a number of
charge from intensive care or hospital, although timing potential difficulties post-tracheostomy;
has to be flexible given the length of hospital stay for these can be identified and the patient
referred to the appropriate specialist
152
some patients. For many, one appointment is sufficient,
but others have continuing problems and may need to Sleep and eating Sleep and concentration disturbances are
return on a number of occasions. Some clinics routinely common, and muscle loss and weakness
are important contributors to delayed
offer return appointments up to one year after discharge, recovery 109
determined on an individual patient basis. Attendance 192,194
can be problematic; only 70–90% in some studies. 146,153 Urology/ Patients may have sexual problems
192
reproduction,
and skin and nail problems
Non-attendance can occur because a patient has no iden- skin and senses
tified problems (shorter ICU LOS; less ill); or more
importantly because of individual limitations (limited Recreation, work Patients may experience difficulties
and lifestyle
reintegrating into society and in
mobility; living a distance away from the clinic, or signifi- change particular returning to work 192
cant post-traumatic stress symptoms including avoidant
behaviours). 153 Intensive care Patients rarely remember factual events of
experience
their time in ICU, but their memories are
While these services developed in a relatively ad hoc often of unpleasant and disturbing
54,58,85
manner, tended to be underfunded and used a variety of events; offering an opportunity to
discuss actual events and sometimes
models in their delivery, the purposes for such a service distressing memories can be
are similar (see Box 4.1). beneficial 152
Quality of life The ultimate aim of treatment and care is
Clinic Activities to return a patient to an acceptable and
Patient progress is reviewed for identification of subse- optimal quality of life; it is important to
gauge how patients perceive their life
quent problems, and timely referral to appropriate ser- quality, and may identify areas for
vices for further treatment. A major advantage of follow-up practice improvement 53
clinics is the increased understanding of patient recovery,
as a range of physical and psychological assessments can
be conducted (see an example in Table 4.7). Content of
assessment is informed by the understanding and knowl- status can also be assessed using a number of neuro-
edge of the problems patients commonly face during cognitive tests including Ravens Progressive Matrices,
their recovery period. Critical care and rehabilitation Hayling Sentence and the Six Element test. The issue of
77
staff, however, need to ensure that issues are not ‘prob- respondent burden must be considered and question-
lematising’ for aspects of recovery that is not of concern naire fatigue recognised. This can be managed in part by
to the patient. asking patients to bring completed questionnaires with
them to the clinic appointment. Administration, scoring
Content of an assessment tool structures the clinic visit and interpretation of questionnaires must also be
and identifies any patient problems. These assessments managed in accordance with instrument guidelines.
can include the use of standardised questionnaires of
HRQOL and psychological status, and other free-text Referral to appropriate specialties using a systematic
responses that incorporate patient comments and other approach and timely response times are necessary, as
issues. Use of standardised questionnaires is however other healthcare professionals will not usually be present
151
inconsistent which limits evaluation and comparisons when patients attend the clinic. Delays in treatment fol-
of clinic outcomes. Common examples of questionnaires lowing identification of significant post-traumatic symp-
were previously listed in Tables 4.1 and 4.3. Cognitive tomatology can result in PTSD that is enduring and lasts

70 S C O P E O F C R I T I C A L C A R E

81
for several years. Implementing defined referral criteria them having no identified problems or unanswered ques-
and pathways can however be challenging particularly tions about the patient’s recovery, or being unable to
when a clinic is nurse-led. 146 While identification of refer- attend because of work commitments. Some relatives,
rals during a follow-up clinic reflect a potential unmet however, may not attend because of also adopting avoid-
need for these patients, one survey reported that 51% of ant strategies if they are experiencing posttraumatic stress
151
clinics had no formal referral mechanisms. This referral symptomatology 156 or other health problems.
activity also reflects an additional function of the clinic in
coordinating patient care after hospital discharge. Clinic Evaluation
Coordination of care for these patients with complex Given the development of follow-up clinics and the
needs often includes multiple out-patient appointments nature of implementation, formal evaluation is difficult
and investigations at a time when they are least able to and this is reflected in the paucity of empirical evidence.
cope with this complexity. An additional patient benefit Anecdotally, nurses who deliver these clinics consider
of returning to a follow-up clinic is in supporting them them beneficial and patients seem to value them. Intui-
to negotiate their way through this complex care, tively it is a good idea for intensive care practitioners who
co-ordinate out-patient appointments, and to have have unique insights into patient experiences, to follow
someone who they know help them understand and their patients after discharge. Three approaches to
interpret the whole critical illness and recovery experi- follow-up clinic evaluation are evident: a service evalua-
152
153
ence. This coordinating role was unforeseen in a recent tion, a qualitative study and a pragmatic, randomised
146
study evaluating the effectiveness of a nurse-led clinic. 146 controlled trial; each providing different insights.
Twenty-five interviews were performed to evaluate one
The follow-up clinic can also be a vehicle for supporting service, with a number of important themes evident:
and evaluating a rehabilitation program. Rehabilitation patients valued easy access to the clinic, being well-treated
91
in the form of a 6-week supported self-help manual with by staff and not having to wait long to be seen. Some
weekly telephone calls and completion of a diary dem- patients attended because they simply received the
onstrated an improvement in physical recovery at 8 weeks appointment, while others identified the need to have
and 6 months after intensive care discharge. questions answered, and wanted to discuss their distress-
153
ing dreams and hallucinations. While there was an
As noted earlier, a unique element of a patient’s intensive
care experience is their limited recall of factual events but insightful account of the development and initial evalu-
a common experience of ‘nightmares’ and ‘hallucina- ation, no demonstrable patient benefits were evident.
tions’ that can be distressing both at the time and during Four main themes emerged from another study of 34
recovery. The benefits of having an opportunity to discuss patients: continuity of care; receiving information;
their experiences with intensive care staff should not be importance of expert reassurance and giving feedback to
underestimated. Patients value being able to speak to intensive care staff. Continuity of care enabled reas-
152
‘experts’ about their experience, be given information surance to patients that their progress was being moni-
about what happened to them in ICU and also receive tored and any problems dealt with if referral to other
reassurances about the length of time that recovery will specialties was needed. Opinions varied about the
take and that their distressing memories are common. number of clinic appointments and this reflects indi-
Clinics also offer patients the opportunity to comment vidual perceptions and needs. Receiving information was
on their care both during and after intensive care. 152,153 invaluable because of the poor memory for factual events.
This is important not just for the patient but to inform General information about what had happened to them
care delivery. For ICUs who complete patient diaries, the in ICU was also important for gauging the length of time
follow-up clinic is often the place where these are intro- needed for recovery. Patients also found specific informa-
duced and discussed with the patient. 108,154 tion about tracheostomy scars and other specific areas
beneficial. While much of this information could be
Offering the patient an opportunity to visit the ICU is delivered by non-ICU staff, it was noted patients and
possible during the follow-up clinic appointment. As relatives were specifically reassured from experts familiar
noted earlier, the lack of factual memory of intensive care with their ICU experiences. Being informed that other
152
often leaves patients with gaps that may be distressing. patients had similar experiences, particularly with prob-
Visiting the ICU may therefore be beneficial for some lems sleeping or the nightmares and hallucinations, was
patients particularly when they report odd perceptual also comforting to patients. Clinics also offered the
experiences, and enable them to make sense of some of patient the opportunity to give feedback to ICU staff,
these experiences. and also allowed patients and relatives to thank staff for
the care received.
A follow-up clinic also provides an important forum for
relatives. Relatives may have different needs to a patient, The PRaCTICaL study randomised eligible patients to a
and it is common to encourage relatives to attend with the control group of usual care (in-hospital review by a
patient. Relatives may not only have short- and long-term liaison nurse) or intervention group (a physical rehabili-
consequences for their emotional wellbeing and physical tation handbook and a nurse-led intensive care follow-up
146
health, 155 but also be faced with supporting a patient who clinic 2–3 months after discharge and 6 months later).
has unrealistic expectations about their recovery. Clinic Referral pathways were developed with ‘fast-track’ access
attendance by relatives varies; 146 and may be related to to psychiatric or psychological services. There was no

Recovery and Rehabilitation 71



TABLE 4.8 Example of considerations in setting up a nurse-led follow-up service

Consideration Action
Staff preparation ● Follow-up Nurse attended an established clinic
● Attended study days in relation to psychiatric problems
● Discussion and frequent contact with Consultant Psychiatrist in Psychotherapy
● Plans to access formal education preparation in Cognitive Behaviour Therapy
● Plans to ‘shadow’ a community psychiatric nurse
Accommodation ● Outpatient accommodation with an area close to but separate from the ICU
In-hospital follow-up ● All level patients are seen prior to hospital discharge where the follow-up clinic is explained and an
appointment given; relatives are included in this appointment
● The options for telephone consultation and/or home visits are discussed and negotiated
Timing of clinic and number of ● Initial appointment 2–3 months after ICU discharge
appointments ● Further appointments determined by patient need or request
● All patients can contact the follow-up nurse without formal appointments
Structure of clinic ● Patients’ case notes reviewed prior to the clinic appointment and discussed between nurse and
intensivist
● General assessment questionnaire forms the basis of the discussion between the nurse and patient
● Standardised measures include: Short-Form 36, Hospital Anxiety and Depression Scale, and Intensive
Care Experience Questionnaire
● Patients are offered a visit to the ICU if they do not ‘trigger’ referral on the Hospital Anxiety and
Depression Scale
Documentation ● General assessment questionnaire forms the basis of the record of appointment; the nurse records any
additional information on this form
Referral criteria ● There are clear referral criteria for a number of specialties, developed in collaboration with intensivists,
other medical specialties and allied health professionals
Letter to General Practitioner ● A letter summarising the appointment and any recommendations is sent to the patient’s GP




demonstrated differences between groups for the primary Other considerations
(HRQOL: SF-36) or secondary outcome measures It is important to consider that while interventions may
(anxiety and depression: Hospital Anxiety and Depres- not always benefit patients, it also has to be demonstrated
sion Scale; post-traumatic stress: Davidson Trauma that they cause no harm and therefore initiating a new
Scale). There were also no differences between patients service has governance issues. There are also knowledge
who had a short intensive care stay and those with and skill-set development issues. Intensive care nurses
longer stays. 146
tend not to have training in managing patients on an
There is little doubt that patients value intensive care outpatient basis and new skills have to be learned. They
follow-up, but there is no evidence to support any may also not have knowledge and experience in manag-
improved patient outcomes. 157 There may be a number ing many of the patient problems evident at follow-up,
146
of reasons for this finding. The study intervention was in particular the psychological issues. Other consider-
based on existing models of ICU follow-up and our con- ations include accommodation, documentation, com-
temporary understanding of patient recovery has evolved munication with other healthcare professionals and
since then. For example, no recognition was made of evaluation processes. Table 4.8 provides an example of
cognitive function and the effects of delirium, and perhaps how these issues were addressed when setting up a
the timing of the intervention was too late. It may also follow-up service in a Scottish teaching hospital; an
be that particular subgroups benefited, e.g. those who evolving service that developed from the PRaCTICaL
received psychiatric or psychological referral, but the study. 146 A more flexible approach is used with different
study was not sufficiently powered to detect this. options discussed with the patient regarding delivery,
with a telephone consultation, home visit and/or clinic
Other models that allow more flexibility should therefore appointment.
be considered. Telephone contact in the initial weeks
after discharge can offer some reassurance to patients and
also identify early problems. Patients could then be either HOME-BASED CARE
referred to other specialties, their outpatient appoint- While there are home-based programs to manage ongoing
ments coordinated or invited to return to a follow-up care for some clinical cohorts (e.g. patients with heart
clinic if they experience identified difficulties. Home visits failure) no specific follow-up programs currently exist to
could also be an option for those who are physically or support survivors of a critical illness. Initial studies in this
practically unable to return to a clinic or for those with setting are also yet to identify an optimal intervention to
avoidant behaviours. improve recovery. A recent Australian multi-site study

72 S C O P E O F C R I T I C A L C A R E

demonstrated that an individualised 8-week home-based should enable the development of a series of seamless
physical rehabilitation program did not increase the services that start recovery and rehabilitation activities for
underlying rate of recovery in a sample of 183 patients, a patient while in ICU, is carried through to hospital
with no group differences identified for 6MWT distances discharge and continues into the community setting.
or HRQOL at 8 weeks or 6 months. 158 The authors recom-
mended further research to improve the effects of the
intervention by increasing exercise intensity and fre- SUMMARY
quency, and identifying individuals who would benefit It is now acknowledged that continuity of care for indi-
from a home-based rehabilitation intervention. Other viduals with a critical illness extends beyond the immedi-
research is continuing in this area, but findings are not ate event to include non-ICU hospital care and community
yet available. e.g.131 Findings from other clinical cohorts services. Physical and psychological sequelae for some
may also inform the development of rehabilitation inter- individuals following a critical illness are well docu-
ventions, for example with the use of web-based or mented. Beginning physical rehabilitation and a range of
mobile technologies. 159
psychological strategies have been used to limit these
Further research is therefore also required in this post- effects in some studies, although more comprehensive
hospital period 160 as well as across the continuum of and system-wide interventions require implementation
critical illness. e.g.131 With further study, future continuity and evaluation to improve the evidence base for this
of care and follow-up services after hospital discharge important area of critical care practice.



Case study

Mr Gilardi was a 55-year-old man admitted to ICU with community- admission to ICU would occur. The doctor contacted the liaison
acquired pneumonia. He required five days of mechanical ventila- nurse service for advice as to how to support Mr Gilardi.
tion and was then discharged to the high dependency unit for
three days and then to a medical ward. An ICU liaison nurse saw A liaison nurse phoned Mr Gilardi to invite himself and his family
him three times prior to discharge from the ward where he initially to attend for a review of his time in ICU with the now established
had some confusion and was suffering from hallucinations. He did ICU follow-up service. At his appointment he reported recurrent
have some insight into this and reported that this was no longer nightmares, difficulty in sleeping, was not keen to go outside, and
bothering him. An ICU follow-up service was not in operation at was finding it difficult to discuss any events surrounding his ICU
the time of his discharge home. admission. These symptoms had now been present for almost a
year, and the follow-up nurse was concerned that Mr Gilardi may
Mr Gilardi then attended an outpatient review for a recurring have developed a posttraumatic stress disorder. The nature of his
gastrointestinal problem a few months later. At this appointment enduring symptoms was discussed, and it was decided that the
his doctor was concerned that he still appeared to be traumatised best course of action was for him to be referred to the local liaison
psychologically by his ICU experience. This was highlighted when mental health services. Mr Gilardi is now receiving psychiatric care
Mr Gilardi stated that he did not want any further treatment for with the aim of improving his quality of life and allowing him to
his gastrointestinal problem if there was any possibility that an undergo additional treatment for his gastrointestinal issue.




Research vignette
Jones C, Bäckman C, Capuzzo M, Egerod I, Flaatten H et al. Intensive development of acute PTSD. The intervention patients received
care diaries reduce new onset post traumatic stress disorder fol- their ICU diary at 1 month following critical care discharge and the
lowing critical illness: a randomised, controlled trial. Critical Care final assessment of the development of acute PTSD was made at 3
2010; 14(5): R168–R178. months.
Abstract Results
Introduction 352 patients were randomised to the study at 1 month. The inci-
Patients recovering from critical illness have been shown to be at dence of new cases of PTSD was reduced in the intervention group
risk of developing Post Traumatic Stress disorder (PTSD). This study compared to the control patients (5% versus 13%, P = 0.02).
was to evaluate whether a prospectively collected diary of a Conclusions
patient’s intensive care unit (ICU) stay when used during convales- The provision of an ICU diary is effective in aiding psychological
cence following critical illness will reduce the development of new recovery and reducing the incidence of new PTSD.
onset PTSD. Critique
Methods Despite a relative lack of empirical data, the use of patient diaries
Intensive care patients with an ICU stay of more than 72 hours were for ICU patients has become popular innovation over the last
recruited to a randomised controlled trial examining the effect few years. As noted earlier in this chapter, patients’ memories of
of a diary outlining the details of the patients ICU stay on the intensive care have been consistently related to subsequent

Recovery and Rehabilitation 73



Research vignette, Continued

psychological outcome, and providing a factual account of their intervention patients and 48% of the controls identified their ICU
ICU stay intuitively appears to be a sensible approach to improve experience as a traumatic event. Most patients (87%) in the inter-
this outcome. This reviewed paper reported an international multi- vention group received their diaries at randomisation, and shared
centre randomised controlled trial evaluating the effect of a patient these with others. On the whole patients found both text and
diary on the incidence of new cases of post traumatic stress disor- photographs in the diaries helpful.
der (PTSD) in patients with an ICU stay of 72 hours of more and The study has a number of strengths. The sample size was large for
mechanical ventilation of 24 hours or more.
an ICU study and there was limited attrition. Appropriate measures
Participants were patients admitted to one of 12 ICUs in six Euro- were used that addressed the DSM-IV criteria. Administration of
pean countries. Inclusion and exclusion criteria were clearly the PDS varied according to whether a patient could return to the
described and good rationale given for these. Patients were hospital, and for those who could not, the PDS was administered
excluded with preexisting psychotic illness or if they had been by telephone. As the authors stated, it would have been beneficial
previously diagnosed with PTSD. All participating units had experi- if the PDS had been administered on two occasions: at 1 month
ence of using patient diaries and these were standardised through and 3 months. However this was not thought feasible given the
a designated diary group on each unit. One of the strengths of patient effort to complete the measure.
this paper was the use of standardised measures previously used
in the intensive care population to assess patients’ memories of The international focus suggests good generalisability within
intensive care (ICU Memory Tool), posttraumatic stress symptoms Europe but this would have been strengthened if a brief descrip-
(Post-Traumatic Stress Syndrome 14 [PTSS-14]) and posttraumatic tion of each unit had been provided and the breakdown of recruit-
stress disorder (Posttraumatic Diagnostic Scale [PDS]). Patients ment to each unit had been presented. However, word limits in
were recruited to the study approximately one week after dis- journal papers often do not allow for this. The diary as an interven-
charge from ICU and randomised about one month later after tion was well developed and standardised and the use of a limited
baseline completion of the PTSS-14. Individuals in the control number of researchers enhanced the validity of the findings. Clini-
group received their diaries after completion of the outcome cal studies have a number of challenges. It is often important to try
measure (around 3 months after discharge), while those in the to reflect practice that is feasible and practical within a clinical
intervention group received theirs as soon as requested. The setting and this study acknowledges this.
diaries were introduced to the patient by a research nurse or The findings from this study are encouraging and add to our
doctor. The PDS was the main outcome measure, assessed all des- understanding of the effectiveness of using patient diaries. A
ignated DSM-IV criteria of PTSD and was administered as a diag- smaller UK-based study had also found a reduction in anxiety and
nostic interview. depression in patients who had received diaries. Both studies
161
evaluated the effectiveness of diaries over a relatively short period
Three hundred and fifty two patients were recruited over a of time. PTSD may have late or delayed onset, has been shown not
12-month period, and 322 completed the three month follow-up to reduce over time and in fact tends to be enduring. It is therefore
assessment (control n = 160: intervention n = 162). Group equiva- important to be confident that any intervention causes no harm to
lence was established although there were more females in the patients and further study that explores the longer-term effect of
control group. Findings demonstrated that patients who had been the diaries would be beneficial.
exposed to a diary were less likely to be diagnosed with new onset
PTSD: 5% versus 13% (chi-squared = 7.15, P = 0.02). There was Importantly, this study identified an issue common to many ICU
however no overall difference in the PTSS-14 scores between 1 and studies: it demonstrates that these ‘blanket’ interventions tend not
3 months between control and intervention patients (Mann to be effective in this patient group but rather we need to target
Whitney U P = 0.737). A post-hoc analysis did identify a difference those patients who will benefit from either a physical or psycho-
between groups in the small number of patients who ‘triggered’ a logical intervention. Larger studies that allow subgroup analysis
cut-off score in the PTSS-14 at 1 month. Importantly 43% of the are necessary to do this.





Learning activities
1. Patients transferred from ICU to the ward may have complex Items 4–5 relate to the case study on p. 72.
care needs. In your hospital, who assesses these physical, psy- 4. How and when should Mr Gilardi have been screened or
chological and cognitive needs and ensures that appropriate assessed specifically for PTS symptoms?
health professionals become involved in the patient’s care? 5. Suggest a plan of care that might have minimised or prevented
When does this assessment take place? Mr Gilardi’s ongoing psychological distress.
2. Review the evidence of PTSD assessment and management for
patients after a critical illness and intensive care admission.
3. What are the educational implications for staff in relation to
supporting the psychological problems patients experience
after ICU?

74 S C O P E O F C R I T I C A L C A R E

ONLINE RESOURCES 21. Pandharipande P, Banerjee A, McGrane S, Ely EW. Liberation and animation
for ventilated ICU patients: the ABCDE bundle for the back-end of critical
I-CAN UK (Intensive Care After Care Network), <http://www.i-canuk.co.uk/ care. Crit Care 2010; 14(3): 157.
default.aspx> 22. Girard TD, Kress JP, Fuchs BD, Thomason JWW, Schweickert WD et al. Effi-
ICU Steps, <http://www.icusteps.com> cacy and safety of a paired sedation and ventilator weaning protocol for
Intensive Care Recovery Manual, St Helens and Knowsley Hospitals NHS Trust, mechanically ventilated patients in intensive care (Awakening and Breathing
<http://www.sthk.nhs.uk/library/documents/icurecoverymanual2009.pdf> Controlled trial): a randomised controlled trial. Lancet 2008; 371(9607):
Patient-reported Outcome and Quality of Life Instruments Database (PRO- 126–34.
QOLID), <http://www.proqolid.org> 23. Fan E, Zanni JM, Dennison CR, Lepre SJ, Needham DM. Critical illness
PTSD NICE Guidelines, <http://www.nice.org.uk/CG26> neuromyopathy and muscle weakness in patients in the intensive care unit.
AACN Adv Crit Care 2009; 20(3): 243.
24. Stevens RD, Marshall SA, Cornblath DR, Hoke A, Needham DM et al. A
FURTHER READING framework for diagnosing and classifying intensive care unit-acquired weak-
ness. Crit Care Med 2009; 27(10 [Suppl.]): S299–308.
Oeyen SG, Vandijck DM, Benoit DD, Annemans L, Decruyenaere JM. Quality of 25. Griffiths RD, Hall JB. Intensive care unit-acquired weakness. Crit Care Med
life after intensive care: a systematic review of the literature. Crit Care Med 2010; 2010; 38(3): 779–87.
38(12): 2386–400. 26. Truong AD, Fan E, Brower RG, Needham DM. Bench-to-bedside review:
National Institute for Health and Clinical Excellence. Rehabilitation after critical mobilizing patients in the intensive care unit – from pathophysiology to
illness. NICE clinical guideline 83. 2009 March:1–91. Available from: http:// clinical trials. Crit Care 2009; 13: 216–24.
www.nice.org.uk/CG83 27. Winkelman C. Bed rest in health and critical illness. AACN Adv Crit Care
2009; 20(3): 254–66.
28. Sliwa JA. Acute weakness syndromes in the critically ill patient. Arch Phys
REFERENCES Med Rehabil 2000; 81(3 [Supp. 1]): S45–54.
29. Cheung AM, Tansey CM, Tomlinson G, Diaz-Granados N, Matte A et al.
1. Drennan K, Hicks P, Hart GK. Intensive care resources and activity: Australia & Two-year outcomes, health care use, and costs of survivors of acute respira-
New Zealand 2007/2008. Melbourne: Australian and New Zealand Intensive tory distress syndrome. Am J Resp Crit Care Med 2006; 174(5): 538.
Care Society; 2010. 30. Cuthbertson BH, Roughton S, Jenkinson D, MacLennan G, Vale L. Quality
2. Williams TA, Dobb GJ, Finn JC, Knuiman MW, Geelhoed E et al. Determi- of life in the five years after intensive care: a cohort study. Crit Care 2010;
nants of long-term survival after intensive care. Crit Care Med 2008; 36: 14(R6): 1–12.
1523–30. 31. Herridge MS, Cheung AM, Tansey CM, Matte-Martyn A, Diaz-Granados N
3. Adamson H, Elliott D. Quality of life after a critical illness: a review of et al. One-year outcomes in survivors of the acute respiratory distress
general ICU studies 1998–2003. Aust Crit Care 2005; 18: 50–60. syndrome. New Eng J Med 2003; 348(8): 683–93.
4. Dowdy DW, Eid MP, Sedrakyan A, Mendez-Tellez PA, Pronovost PJ et al. 32. Strahan EH, Brown RJ. A qualitative study of the experiences of patients
Quality of life in adult survivors of critical illness: a systematic review of the following transfer from intensive care. Intensive Crit Care Nurs 2005; 21(3):
literature. Intensive Care Med 2005; 31(5): 611–20. 160–71.
5. Oeyen SG, Vandijck DM, Benoit DD, Annemans L, Decruyenaere JM. Quality 33. United Kingdom Medical Research Council. Aids to the examination of the
of life after intensive care: a systematic review of the literature. Crit Care Med peripheral nervous system. Edinburgh: W.B. Saunders; 2000.
2010; 38(12): 2386–400. 34. Ali NA, O’Brien JM, Hoffmann SP, Phillips G, Garland A et al. Acquired
6. Stevens RD, Dowdy DW, Michaels RK, Mendez-Tellez PA, Pronovost PJ, weakness, handgrip strength, and mortality in critically ill patients. Am J Resp
Needham DM. Neuromuscular dysfunction acquired in critical illness: A Crit Care Med 2008; 178(3): 261.
systematic review. Intensive Care Med 2007; 33(11): 1876–91. 35. Fan E, Ciesla ND, Truong AD, Bhoopathi V, Zeger SL, Needham DM. Inter-
7. De Jonghe B, Lacherade JC, Durand MC, Sharshar T. Critical illness neuro- rater reliability of manual muscle strength testing in ICU survivors and simu-
muscular syndromes. Neurologic Clinics 2008; 26(2): 507–20. lated patients. Intensive Care Med 2010; 36(6): 1038–43.
8. Griffiths RD, Jones C. Delirium, cognitive dysfunction and posttraumatic 36. Black NA, Jenkinson C, Hayes JA, Young D, Vella K et al. Review of outcome
stress disorder. Curr Opin Anesthesiol 2007; 20(2): 124–9. measures used in adult critical care. Crit Care Med 2001; 29(11): 2119–24.
9. Angus DC, Carlet J. Surviving intensive care: a report from the 2002 Brussels 37. Ridley S. Critical care outcomes. Anaesthesia 2001; 56(1): 1–3.
Roundtable. Intensive Care Med 2003; 29(3): 368–77. 38. Ferrans CE, Zerwic JJ, Wilbur JE, Larson JL. Conceptual model of health-
10. de Jonghe B, Lacherade JC, Sharshar T, Outin H. Intensive care unit-acquired related quality of life. J Nurs Schol 2005; 37(4): 336–42.
weakness: risk factors and prevention. Crit Care Med 2009; 37(10 Suppl): 39. Hofhuis JGM, van Stel HF, Schrijvers AJP, Rommes JH, Bakker J, Spronk PE.
S309–15. Health-related quality of life in critically ill patients: how to score and what
11. Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L, Dittus RS. Reducing is the clinical impact? Curr Opin Crit Care 2009 ; 15(5): 425–30.
iatrogenic risks: ICU-acquired delirium and weakness – crossing the quality 40. Chaboyer W, Elliott D. Health-related quality of life of ICU survivors: review
chasm. Chest 2010; 138(5): 1224–33. of the literature. Intensive Crit Care Nurs 2000; 16(2): 88–97.
12. Griffiths JA, Morgan K, Barber VS, Young JD. Study protocol: The Intensive 41. Dowdy DW, Eid MP, Dennison CR, Mendez-Tellez PA, Herridge MS et al.
Care Outcome Network (‘ICON’) study. BMC Hlth Serv Res 2008; 8(1): 132. Quality of life after acute respiratory distress syndrome: A meta-analysis.
13. Davydow DS, Gifford JM, Desai SJ, Bienvenu OJ, Needham DM. Depression Intensive Care Med 2006; 32(8): 1115–24.
in general intensive care unit survivors: a systematic review. Intensive Care 42. Elliott D. Measuring the health outcomes of general ICU patients: a system-
Med 2009; 35: 796–809. atic review of methods and findings. Aust Crit Care 1999; 12(4): 132–40.
14. Griffiths J, Fortune G, Barber V, Young JD. The prevalence of post traumatic 43. Buckley TA, Cheng AY, Gomersall CD. Quality of life in long-term survivors
stress disorder in survivors of ICU treatment: a systematic review. Intensive of intensive care. Annals Acad Med Singapore 2001; 30(3): 287–92.
Care Med 2007; 33(9): 1506–18. 44. Needham DM, Dowdy DW, Mendez-Tellez PA, Herridge MS, Pronovost P.
15. Girard TD, Jackson JC, Pandharipande PP, Pun BT, Thompson JL et al. Studying outcomes of intensive care unit survivors: measuring exposures and
Delirium as a predictor of long-term cognitive impairment in survivors of outcomes. Intensive Care Med 2005; 31: 1153–60.
critical illness. Crit Care Med 2010; 38(7): 1513–20. 45. Hayes JA, Black NA, Jenkinson C, Young JD, Rowan KM et al. Outcome
16. Hopkins RO. Haunted by delusions: Trauma, delusional memories, and measures for adult critical care: a systematic review. Health Technol Assess
intensive care unit morbidity. Crit Care Med 2010; 38(1): 300–301. 2000; 4(24): 1–111.
17. Hopkins RO, Jackson JC. Short- and long-term cognitive outcomes in inten- 46. Vainiola T, Pettila V, Roine RP, Rasanen P, Rissanen AM, Sintonen H. Com-
sive care unit survivors. Clin Chest Med 2009; 30(1): 143. parison of two utility instruments, the EQ-5D and the 15D, in the critical
18. Jackson JC, Mitchell N, Hopkins RO. Cognitive functioning, mental health, care setting. Intensive Care Med 2010; 36: 2090–93.
and quality of life in ICU survivors: an overview. Crit Care Clinics 2009; 47. Katz S, Ford A, Moskowitz R. Studies of illness in the aged: the index of ADL:
25(3): 615–28. a standardized measure of biological and psychosocial function. J Am Med
19. Jones C, Griffiths RD, Slater T, Benjamin KS, Wilson S. Significant cognitive Assoc 1963; 185: 914–19.
dysfunction in non-delirious patients identified during and persisting fol- 48. Karnofsky D, Abelmann W, Craver L, Burchenal J. The use of nitrogen mus-
lowing critical illness. Intensive Care Med 2006; 32: 923–6. tards in the palliative treatment of cancer. Cancer 1948; 1: 634–56.
20. Rubenfeld GD, Curtis JR. Health status after critical illness: Beyond descrip- 49. Lawton MP, Brody BM. Assessment of older people:self-maintaining and
tive studies. Intensive Care Med 2003; 29(10): 1626–8. instrumental activities of daily living. Gerontologist 1969; 9: 179–86.

Recovery and Rehabilitation 75

50. Borg GA. Psychophysical bases of perceived exertion. Med & Sci Sports & 77. Sukantarat KT, Burgess PW, Williamson RCN, Brett SJ. Prolonged cognitive
Exercise 1982; 14: 377–81. dysfunction in survivors of critical illness. Anaesthesia 2005; 60(9):
51. American Thoracic Society. Guidelines for the six-minute walk test. Am J Resp 847–53.
Crit Care Med 2002; 166: 111–17. 78. McKinney AA, Deeny P. Leaving the intensive care unit: a phenomenological
52. Jones C, Humphris GM, Griffiths RD. Psychological morbidity following study of the patients’ experience. Intensive Crit Care Nurs 2002; 18(6):
critical illness: the rationale for care after intensive care. Clin Intensive Care 320–31.
1998; 9: 199–205. 79. Maddox M, Dunn SV, Pretty LE. Psychosocial recovery following ICU: experi-
53. Rattray JE, Hull AM. Emotional outcome after intensive care: literature ences and influences upon discharge to the community. Intensive Crit Care
review. J Adv Nurs 2008; 64(1): 2. Nurs 2001; 17(1): 6–15.
54. Rattray J, Johnston M, Wildsmith JAW. The intensive care experience: devel- 80. de Miranda S, Pochard F, Chaize M, Megarbane B, Cuvelier A et al. Postint-
opment of the ICE questionnaire. J Adv Nurs 2004; 47(1): 64–73. ensive care unit psychological burden in patients with chronic obstructive
55. Jones C. Aftermath of intensive care: the scale of the problem. Brit J Hosp pulmonary disease and informal caregivers: A multicenter study. Crit Care
Med 2007; 68(9): 464–6. Med 2011; 39(1): 112–18.
56. Jones C, Twigg E, Lurie A, McDougall M, Heslett R et al. The challenge of 81. Kapfhammer HP, Rothenhäusler HB, Krauseneck T, Stoll C, Schelling G.
diagnosis of stress reactions following intensive care and early intervention: Posttraumatic stress disorder and health-related quality of life in long-term
a review. Clin Intensive Care 2003; 14: 83–9. survivors of acute respiratory distress syndrome. Am J Psychiatry 2004;
57. Jones C, Griffiths RD, Humphris G, Skirrow PM. Memory, delusions, and 161(1): 45–52.
the development of acute posttraumatic stress disorder-related symptoms 82. Dowdy DW, Bienvenu OJ, Dinglas VD, Mendez-Tellez PA, Sevransky J et al.
after intensive care. Crit Care Med 2001; 29(3): 573–80. Are intensive care factors associated with depressive symptoms 6 months
58. Adamson H, Murgo M, Boyle M, Kerr S, Crawford M, Elliott D. Memories after acute lung injury? Crit Care Med 2009; 37(5): 1702–7.
of intensive care and experiences of survivors of a critical illness: an interview 83. Eddleston JM, White P, Guthrie E. Survival, morbidity, and quality of
study. Intens Crit Care Nurs 2004; 20: 257–63. life after discharge from intensive care. Crit Care Med 2000; 28(7):
59. Ringdal M, Plos K, Ortenwall P, Bergbom I. Memories and health-related 2293–9.
quality of life after intensive care: a follow-up study. Crit Care Med 2010; 84. Myhren H, Tøien K, Ekeberg O, Karlsson S, Sandvik L, Stokland O. Patients’
38(1): 38–44. memory and psychological distress after ICU stay compared with expecta-
60. Brewin CR. Systematic review of screening instruments for adults at risk of tions of the relatives. Intensive Care Med 2009; 35(12): 2078–86.
PTSD. J Trauma Stress 2005; 18(1): 53–62. 85. Rattray JE, Johnson M, Wildsmith JAW. Predictors of emotional outcomes of
61. Gordon SM, Jackson JC, Ely EW, Burger C, Hopkins RO. Clinical identifica- intensive care. Anaesthesia 2005; 60: 1085–92.
tion of cognitive impairment in ICU survivors: insights for intensivists. 86. Myhren H, Ekeberg O, Tøien K, Karlsson S, Stokland O. Posttraumatic stress,
Intensive Care Med 2004; 30(11): 1997–2008. anxiety and depression symptoms in patients during the first year post
62. Jackson JC, Gordon MW, Ely EW, Burger C, Hopkins RO. Research issues in intensive care unit discharge. Crit Care 2010; 14(1): 125.
the evaluation of cognitive impairment in intensive care unit survivors. 87. Hopkins RO, Weaver LK, Chan KJ, Orme JF. Quality of life, emotional, and
Intensive Care Med 2004; 30(11): 2009–16. cognitive function following acute respiratory distress syndrome. J Int Neu-
63. Hopkins RO, Weaver LK, Pope D, Orme JF, Bigler ED, Larson LV. Neuropsy- ropsychol Soc 2004; 10(7): 1005–17.
chological sequelae and impaired health status in survivors of severe acute 88. Scragg P, Jones A, Fauvel N. Psychological problems following ICU treat-
respiratory distress syndrome. Am J Resp Crit Care Medicine 1999; 160(1): ment. Anaesthesia 2001; 56(1): 9–14.
50–56. 89. Zigmond A, Snaith R. The hospital anxiety and depression scale. Acta Psychi-
64. Chan RC, Shum D, Toulopoulou T, Chen EY. Assessment of executive func- atrica Scandinavica 1983; 67(6): 361–70.
tions: review of instruments and identification of critical issues. Arch Clin 90. Nelson BJ, Weinert CR, Bury CL, Marinelli WA, Gross CR. Intensive care unit
Neuropsychol 2008; 23(2): 201–16. drug use and subsequent quality of life in acute lung injury patients. Crit
65. Granja C, Gomes E, Amaro A, Ribeiro O, Jones C et al. Understanding post- Care Med 2000; 28(11): 3626–30.
traumatic stress disorder-related symptoms after critical care: The early 91. Jones C, Skirrow P, Griffiths RD, Humphris GH, Ingleby S et al. Rehabilita-
illness amnesia hypothesis. Crit Care Med 2008; 36(10): 2801. tion after critical illness: a randomized, controlled trial. Crit Care Med 2003;
66. Granja C, Lopes A, Moreira S, Dias C, Costa-Pereira A, Carneiro A. Patients’ 31(10): 2456–61.
recollections of experiences in the intensive care unit may affect their quality 92. Jackson JC, Hart RP, Gordon SM, Shintani A, Truman B et al. Six-month
of life. Crit Care 2005; 9: R96–109. neuropsychological outcome of medical intensive care unit patients. Crit
67. Boyle M, Murgo M, Adamson H, Gill J, Elliott D, Crawford M. The effect of Care Med 2003; 31(4): 1226–34.
chronic pain on health related quality of life amongst intensive care survi- 93. Hopkins RO, Weaver LK, Collingridge D, Parkinson RB, Chan KJ, Orme Jr JF.
vors. Aust Crit Care 2004; 17: 104–13. Two-year cognitive, emotional, and quality-of-life outcomes in acute respira-
68. Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term tory distress syndrome. Am J Resp Crit Care Med 2005; 171(4): 340.
psychological effects of daily sedative interruption on critically ill patients. 94. Capuzzo M, Valpondi V, Cingolani E, Gianstefani G, De Luca S et al. Post-
Am J Resp Crit Care Med 2003; 168(12): 1457–61. traumatic stress disorder-related symptoms after intensive care. Minerva Anes-
69. Jones C, Humphris G, Griffiths RD. Preliminary validation of the ICUM tool: tesiologica 2005; 71(4): 167–79.
A tool for assessing memory of the intensive care experience. Clinical Inten- 95. Tedstone JE, Tarrier N. Posttraumatic stress disorder following medical
sive Care 2000; 11(5): 251–5. illness and treatment. Clin Psychol Review 2003; 23(3): 409–48.
70. Löf L, Berggren L, Ahlström G. ICU patients’ recall of emotional reac- 96. O’Donnell ML, Creamer M, Pattison P. Posttraumatic stress disorder and
tions in the trajectory from falling critically ill to hospital discharge: depression following trauma: understanding comorbidity. Am J Psychiatry
Follow-ups after 3 and 12 months. Intensive Crit Care Nurs 2008; 24(2): 2004; 161(8): 1390–96.
108–21. 97. Foa EB, McNally R, Murdock TB. Anxious mood and memory. Behav Res Ther
71. Stein-Parbury J, McKinley S. Patients’ experiences of being in an intensive 1989; 27(2): 141–7.
care unit: a select literature review. Am J Crit Care 2000; 9(1): 20–27. 98. Brewin CR, Andrews B, Rose S, Kirk M. Acute stress disorder and posttrau-
72. Davydow DS, Gifford JM, Desai SV, Needham DM, Bienvenu OJ. Posttrau- matic stress disorder in victims of violent crime. Am J Psychiatry 1999;
matic stress disorder in general intensive care unit survivors: A systematic 156(3): 360–66.
review. Gen Hosp Psych 2008; 30(5): 421–34. 99. American Psychiatric Association. Diagnostic and statistical manual of mental
73. Schelling G, Stoll C, Haller M, Briegel J, Manert W et al. Health- disorders 4th edn, text revision (DSM-IV-TR). Washington, DC: American Psy-
related quality of life and posttraumatic stress disorder in survivors of chiatric Association; 2000.
the acute respiratory distress syndrome. Crit Care Med 1998; 26(4): 100. Jackson J, Hart R, Gordon S, Hopkins R, Girard T, Ely EW. Post-traumatic
651–9. stress disorder and post-traumatic stress symptoms following critical illness
74. Cuthbertson BH, Hull A, Strachan M, Scott J. Post-traumatic stress disorder in medical intensive care unit patients: assessing the magnitude of the
after critical illness requiring general intensive care. Intensive Care Med 2004; problem. Crit Care 2007; 11(1): R27.
30(3): 450–55. 101. Perrins J, King N, Collings J. Assessment of long-term psychological well-
75. Rundshagen I, Schnabel K, Wegner C, am Esch S. Incidence of recall, night- being following intensive care. Intensive Crit Care Nurs 1998; 14(3):
mares, and hallucinations during analgosedation in intensive care. Intensive 108–16.
Care Med 2002; 28(1): 38–43. 102. Granberg A, Engberg IB, Lundberg D. Acute confusion and unreal experi-
76. Magarey JM, McCutcheon HH. ‘Fishing with the dead’ – Recall of memories ences in intensive care patients in relation to the ICU syndrome. Part II.
from the ICU. Intensive Crit Care Nurs 2005; 21(6): 344–54. Intensive Crit Care Nurs 1999; 15(1): 19–33.

76 S C O P E O F C R I T I C A L C A R E

103. Jones C, Humphris G, Griffiths RD. Preliminary validation of the ICUM tool: failure: a quality improvement project. Arch Physical Med & Rehab 2010;
a tool for assessing memory of the intensive care unit experience. Clinical 91(4): 536–42.
Intensive Care 2000; 11: 251–5. 131. Denehy L, Berney S, Skinner E, Edbrooke L, Warrillow S et al. Evaluation of
104. Russell S. An exploratory study of patients’ perceptions, memories and expe- exercise rehabilitation for survivors of intensive care: protocol for a single
riences of an intensive care unit. J Adv Nurs 1999; 29(4): 783–91. blind randomised controlled trial. Open Crit Care Med J 2008; 1(1):
105. Weinert CR, Sprenkle M. Post-ICU consequences of patient wakefulness and 39–47.
sedative exposure during mechanical ventilation. Intensive Care Med 2008; 132. Van de Meent H, Baken BCM, Van Opstal S, Hogendoorn P. Critical illness
34(1): 82–90. VR rehabilitation device (X-VR-D): evaluation of the potential use for early
106. Backman CG, Walther SM. Use of a personal diary written on the ICU during clinical rehabilitation. J Electromyography & Kinesiology 2008; 18(3): 480–86.
critical illness. Intensive Care Med 2001; 27(2): 426–9. 133. Daffurn K, Bishop GF, Hillman KM, Bauman A. Problems following dis-
107. Bergbom I, Svensson C, Berggren E, Kamsula M. Patients’ and relatives’ charge after intensive care. Intensive Crit Care Nurs 1994; 10(4): 244–51.
opinions and feelings about diaries kept by nurses in an intensive care unit: 134. Williams TA, Leslie GD, Finn J, Brearley L, Asthifa M et al. Clinical effective-
pilot study. Intensive Crit Care Nurs 1999; 15(4): 185–91. ness of a critical care nursing outreach service in facilitating discharge from
108. Jones C, Bäckman C, Capuzzo M, Egerod I, Flaatten H et al. Intensive care the intensive care unit. Am J Crit Care 2010; 19(5): e63–72.
diaries reduce new onset post traumatic stress disorder following critical 135. Eliott SJ, Ernest D, Doric AG, Page KN, Worrall-Carter LJ et al. The impact
illness: a randomised, controlled trial. Crit Care 2010; 14(5): R168. of an ICU liaison nurse service on patient outcomes. Crit Care Resusc 2008;
109. National Institute for Health and Clinical Excellence. Rehabilitation after 10(4): 296–300.
critical illness. NICE clinical guideline 83. 2009: Available from: http:// 136. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D et al. Introduction of
www.nice.org.uk/CG83. the medical emergency team (MET) system: a cluster-randomised trial.
110. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J et al. Early activity is Lancet 2005; 365: 2091–7.
feasible and safe in respiratory failure patients. Crit Care Med 2007; 35(1): 137. Moran JL, Bristow P, Solomon PJ, George C, Hart GK. Mortality and length-
139–45. of-stay outcomes, 1993–2003, in the binational Australian and New Zealand
111. Morris PE, Goad A, Thompson C, Taylor K, Harry B et al. Early intensive care intensive care adult patient database. Crit Care Med 2008; 36(1): 46–61.
unit mobility therapy in the treatment of acute respiratory failure. Crit Care 138. Fernandez R, Baigorri F, Navarro G, Artigas A. A modified McCabe score for
Med 2008; 36(8): 2238–43. stratification of patients after intensive care unit discharge: the Sabadell
112. Pohlman MC, Schweickert WD, Pohlman AS, Nigos C, Pawlik AJ et al. Fea- score. Crit Care 2006; 10(6): R179.
sibility of physical and occupational therapy beginning from initiation of 139. Fernandez R, Serrano JM, Umaran I, Abizanda R, Carrillo A et al. Ward
mechanical ventilation. Crit Care Med 2010; 38(11): 2089–94. mortality after ICU discharge: a multicenter validation of the Sabadell score.
113. Morris PE, Herridge MS. Early intensive care unit mobility: future directions. Intensive Care Med 2010; 36(7): 1196–201.
Crit Care Clinics 2007; 23(1): 97–110. 140. van der Schaaf M, Dettling DS, Beelen A, Lucas C, Dongelmans DA, Nollet
114. Fan E. What it stopping us from early mobility in the intensive care unit? F. Poor functional status immediately after discharge from an intensive care
[Editorial]. Crit Care Med 2010; 38(11): 2254–5. unit. Disability & Rehabilitation 2008; 30(23): 1812–18.
115. Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D et al. Early exercise 141. Salisbury LG, Merriweather JL, Walsh TS. Rehabilitation after critical illness:
in critically ill patients enhances short-term functional recovery. Crit Care could a ward-based generic rehabilitation assistant promote recovery? Nurs
Med 2009; 37(9): 2499–505. Crit Care 2010; 15(2): 57–65.
116. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ et al. Early 142. Salisbury LG, Merriweather JL, Walsh TS. The development and feasibility of
physical and occupational therapy in mechanically ventilated, critically ill a ward-based physiotherapy and nutritional rehabilitation package for
patients: a randomised controlled trial. Lancet 2009; 373(9678): 1874–82. people experiencing critical illness. Clin Rehabil 2010; 24: 489–500.
117. Stiller K, Phillips A. Safety aspects of mobilising acutely ill inpatients. Physio 143. Langer D, Hendriks EJM, Burtin C, Probst V, van der Schans CP et al. A
Theory Prac 2003; 19(4): 239–57. clinical practice guideline for physiotherapists treating patients with chronic
118. Bailey PP, Miller RR, Clemmer TP. Culture of early mobility in mechanically obstructive pulmonary disease based on a systematic review of available
ventilated patients. Crit Care Med 2009; 37(10 Suppl): S429–35. evidence. Clin Rehabil 2009; 23(5): 445.
119. Gosselink R, Bott J, Johnson M, Dean E, Nava S et al. Physiotherapy for adult 144. de Morton NA, Berlowitz J, Jackson B, Lim WK. Additional exercise does not
patients with critical illness: Recommendations of the European Respiratory change hospital or patient outcomes in older medical patients: a controlled
Society and European Society of Intensive Care Medicine Task Force on clinical trial. Aust J Physiother 2007; 53(2): 105–11.
physiotherapy for critically ill patients. Intensive Care Med 2008; 34(7): 145. Myhren H, Ekeberg O, Stokland O. Health-related quality of life and return
1188–99. to work after critical illness in general intensive care unit patients: A 1-year
120. Clini E, Ambrosino N. Early physiotherapy in the respiratory intensive care follow-up study. Crit Care Med 2010; 38(7): 1554–61.
unit. Respiratory Medicine 2005; 99(9): 1096–204. 146. Cuthbertson BH, Rattray J, Campbell MK, Gager M, Roughton S et al. The
121. Bourdin G, Barbier J, Burle J, Durante G, Passant S et al. The feasibility of PRaCTICal study of nurse led, intensive care follow-up programmes for
early physical activity in intensive care unit patients: a prospective observa- improving long term outcomes from critical illness: a pragmatic randomised
tional one-center study. Respiratory Care 2010; 55(4): 400–407. controlled trial. BMJ 2009; 339: b3723.
122. Needham DM, Truong AD, Fan E. Technology to enhance physical rehabili- 147. McWilliams DJ, Atkinson D, Carter A, Foëx BA, Benington S, Conway DH.
tation of critically ill patients. Crit Care Med 2009; 37(10 [Suppl.]): Feasibility and impact of a structured, exercise-based rehabilitation pro-
S436–41. gramme for intensive care survivors. Physiotherapy Theory & Practice 2009;
123. De Jonghe B, Lacherade J-C, Durand M-C, Sharshar T. Critical illness neuro- 25(8): 566–71.
muscular syndromes. Crit Care Clinics 2007; 23(1): 55–69. 148. Elliott D, McKinley S, Alison JA, Aitken LM, King MT. Study protocol: Home-
124. Cader SA, Vale RG, Castro JC, Bacelar SC, Biehl C et al. Inspiratory muscle based physical rehabilitation for survivors of a critical illness. Crit Care 2006;
training improves maximal inspiratory pressure and may assist weaning in 10: R90.
older intubated patients: a randomised trial. J Physiother 2010; 56(3): 149. UK NHS Audit Commission. Critical to Success. The place of efficient and
171–7. effective critical care services within the acute hospital. In: Audit Commission.
125. Choi JY, Tasota FJ, Hoffman LA. Mobility interventions to improve outcomes London: Editor; 1999.
in patients undergoing prolonged mechanical ventilation: a review of the 150. UK Department of Health. Comprehensive critical care. a review of adult critical
literature. Biological Res Nurs 2008; 10(1): 21. Care services. London: Department of Health; 2000.
126. Korupolu R, Gifford JM, Needham DM. Early mobilization of critically ill 151. Griffiths JA, Barber VA, Cuthbertson BH, Young JD. A national survey of
patients: reducing neuromuscular complications after intensive care. Contemp intensive care follow-up clinics. Anaesthesia 2006; 61: 950–55.
Critical Care 2009; 6(9): 1. 152. Prinjha S, Field K, Rowan K. What patients think about ICU follow-up ser-
127. Skinner EH, Berney S, Warrillow S, Denehy L. Rehabilitation and exercise vices: a qualitative study. Crit Care 2009; 13(2): R46.
prescription in Australian intensive care units. Physiotherapy 2008; 94(3): 153. Cutler L, Brightmore K, Colqhoun V, Dunstan J, Gay M. Developing and
220–29. evaluating critical care follow-up. Nurs Crit Care 2003; 8: 116–25.
128. Morris PE. Moving our critically ill patients: Mobility barriers and benefits. 154. Combe D. The use of patient diaries in an intensive care unit. Nurs Crit Care
Crit Care Clinics 2007; 23(1): 1–20. 2005; 10(1): 31–4.
129. Needham DM. Mobilizing patients in the intensive care unit: improving 155. Paul FBN, Rattray J. Short-and long-term impact of critical illness on rela-
neuromuscular weakness and physical function. JAMA 2008; 300(14): 1685. tives: literature review. J Adv Nurs 2008; 62(3): 276.
130. Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E et al. Early 156. Paul F, Hendry C, Cabrelli L. Meeting patient and relatives’ information
physical medicine and rehabilitation for patients with acute respiratory needs upon transfer from an intensive care unit: the development and

Recovery and Rehabilitation 77

evaluation of an information booklet. J Clin Nurs 2004; 13(3): 175. Mahoney F, Barthek D. Functional evaluation: the Barthel Index. Maryland
396–405. State Med J 1965; 14: 61–5.
157. Williams TA, Leslie GD. Beyond the walls: A review of ICU clinics and their 176. Novak S, Johnson J, Greenwood R. Barthel revisited: making guidelines
impact on patient outcomes after leaving hospital. Aust Crit Care 2008; work. Clin Rehabil 1996; 10(2): 128–34.
21(1): 6–17. 177. Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical
158. Elliott D, McKinley S, Alison JA, Aitken LM, King MT et al. Health-related disability? Disability and Rehabilitation 1988; 10(2): 64–7.
quality of life and physical recovery after a critical illness: a multi-centre 178. Dodds TA, Martin DP, Stolov WC, Deyo RA. A validation of the Functional
randomised controlled trial of a home-based physical rehabilitation Independence Measurement and its performance among rehabilitation inpa-
program. Crit Care 2011; 15: R142. tients. Arch Phys Med Rehabil 1993; 74(5): 531–6.
159. Sarela A, Korhonen I, Salminen J, Koskinen E, Kirkeby O, Walters D. A home- 179. Podsiadlo D, Richardson S. The Timed Up and Go: a test of basic functional
based care model for outpatient cardiac rehabilitation based on mobile mobility for frail elderly persons. J Am Geriatric Soc 1991; 39(2): 142–8.
technologies. Pervasive Health 2009; 5970. 180. Singh SJ, Morgan MD, Scott S, Walters D, Hardman AE. Development of a
160. van der Schaaf M, Beelen A, Dongelmans DA, Vroom MB, Nollet F. Func- shuttle walking test of disability in patients with chronic airways obstruction.
tional status after intensive care: a challenge for rehabilitation professionals BMJ 1992; 47(12): 1019-24.
to improve outome. J Rehabil Med 2009; 41: 360–66. 181. Horowitz M, Wilner N, Alvarez W. Impact of event scale: a measure of subjec-
161. Knowles RE, Tarrier N. Evaluation of the effect of prospective patient diaries tive stress. Psychosomatic Medicine 1979; 41(3): 209–18.
on emotional well-being in intensive care unit survivors: a randomized 182. Weiss DS, Marmar C. The impact of event scale – revised. In: Wilson JP,
controlled trial. Crit Care Med 2009; 37(1): 184–91. Keane TM, eds. Assessing psychological trauma and PTSD: A practitioner’s hand-
162. Ware JE. SF-36 health survey update. Spine 2000; 25(24): 3130–39. book. 2nd edn. New York: Guilford Press; 2004: 168–89.
163. Ware JE, Snow KK, Kosinski M. SF-36 Version 2 Health Survey: Manual and 183. Radloff LS. The CES-D Scale: A self-report depression scale for research in
interpretation guide. Lincoln: Quality Metric Incorporated; 2000. the general population. Applied Psychological Measurement 1977; 1(3):
164. Brooks R. EuroQol: the current state of play. Health Policy 1996; 37: 385–401.
53–72. 184. Sukantarat K, Greer S, Brett S, Williamson R. Physical and psychological
165. Sintonen H. The 15D instrument of health-related quality of life: properties sequelae of critical illness. Brit J Health Psychol 2007; 12(1): 65–74.
and applications. Annals of Medicine 2001; 33: 328–36. 185. Wallen K, Chaboyer W, Thalib L, Creedy DK. Symptoms of acute postrau-
166. Capuzzo M, Grasselli C, Carrer S, Gritti G, Alvisi R. Validation of two quality matic stress disorder after intensive care. Am J Crit Care 2008; 17(6):
of life questionnaires suitable for intensive care patients. Intensive Care Med 534–44.
2000; 26(9): 1296–303. 186. Zanotti E, Felicetti G, Maini M, Fracchia C. Peripheral muscle strength train-
167. Hawthorne G, Richardson J, Osborne R. The Assessment of Quality of Life ing in bed-bound patients with COPD receiving mechanical ventilation.
(AQoL) instrument: a psychometric measure of health-related quality of life. Chest 2003; 124(1): 292.
Qual Life Res 1999; 8(3): 209–24. 187. Chiang LL, Wang LY, Wu CP, Wu HD, Wu YT. Effects of physical training on
168. Rivera-Fernandez R, Sanchez Cruz SJ, G. VMV. Validation of a quality of life functional status in patients with prolonged mechanical ventilation. Physical
questionnaire for critically ill patients. Intensive Care Med 1996; 22: Therapy 2006; 86(9): 1271.
1034–42. 188. Skinner EH, Berney S, Warrillow S, Denehy L. Development of a physical
169. de Bruin AF, Diederikis JP, de Witte LP, Stevens FC, Philipsen H. The develop- function outcome measure (PFIT) and a pilot exercise training protocol for
ment of a short generic version of the Sickness Impact Profile. J Clin Epidemiol use in intensive care. Crit Care Resusc 2009; 11(2): 110–15.
1994; 47: 407–18. 189. Williams TA, Leslie GD, Bingham R, Brearley L. Optimizing seating in the
170. Bergner M, Bobbitt RA, Carter WB, Gilson BS. The sickness impact profile: intensive care unit for patients with impaired mobility. Am J Crit Care 2011;
Development and final revision of a health status measure. Med Care 1981; 20(1): e19–27.
19: 787–805. 190. Griffiths R, Jones C. Seven lessons from 20 years of follow-up of intensive
171. Hunt S, McKenna S, McEwan J, Backett E, Williams J, Papp E. Measuring care unit survivors. Curr Opin Crit Care 2007; 13: 508–13.
health status: a new tool for clinicians and epidemiologists. J Royal College 191. Herridge MS. Legacy of intensive care unit-acquired weakness. Crit Care Med
of Gen Pract 1985; 35: 185–8. 2009; 37(10 Suppl): S457–61.
172. Patrick DL, Danis M, Southerland LI, Hong G. Quality of life following 192. Broomhead LR, Brett SJ. Intensive care follow-up: what has it told us? Critical
intensive care. J Gen Intern Med 1988; 3: 218–23. Care 2002; 6(5): 411–17.
173. Jones PW, Quirk FH, Baveystock CM, Littlejohns P. A self-complete measure 193. Crocker C. A multidisciplinary follow-up clinic after patients’ discharge from
of health status for chronic arirflow limitation: The St George’s Respiratory ITU. Brit J Nurs 2003; 12(15): 910–14.
Questionnaire. Am Rev Respir Dis 1992; 145(6): 1321–7. 194. Griffiths J, Gager M, Alder N, Fawcett D, Waldmann C, Quinlan J. A self-
174. Meguro M, Barley EA, Spencer S, Jones PW. Development and validation of report-based study of the incidence and associations of sexual dysfunction
an improved COPD-specfic version of the St. George Respiratory Question- in survivors of intensive care treatment. Intensive Care Med 2006; 32(3):
naire. Chest 2007; 132: 456–63. 445–51.