Rehabilitation after Critical Illness (RaCI) and Enhanced Recovery after Surgery (ERAS) have been areas of increasing focus in critical care over the last decade. Provision of these care pathways can be challenging. Particularly given financial restraints, and the increasing need to provide 7 day services.
The 22-bedded ICCU at the Freeman Hospital, Newcastle upon Tyne Hospitals (NUTH), has approximately 1,400 admissions per year, of which approximately 70% are elective.
Historical practice at NUTH:
þ All those identified as at risk of physical morbidity have a comprehensive physical assessment
completed at Critical Care admission and discharge
þ Rehabilitation provided as required for all patients Monday—Friday
þ Elective Surgical patients reviewed day 1 for mobilisation by physiotherapist Monday—Friday
þ Respiratory physiotherapy provided 7 days a week
ý Non-physical morbidity is not formally assessed in the
majority of patients.
ý No formal follow up of critical care patients ongoing
rehabilitation needs once discharge from ICCU.
ý Surgical patients not mobilised at weekends.
¨ Develop a RaCI service – weekly outreach rounds and monthly MDT outpatient clinic.
¨ Improve outcomes and recovery pathway for surgical patients.
¨ Provide a more consistent Physiotherapy service on ICCU seven days a week.
¨ Dedicate more therapeutic time to patients with complex respiratory and rehabilitation needs.
¨ Create MDT RaCI pathway documentation
¨ Develop a culture more conducive to rehabilitation involving all members of the ICCU MDT.
Physiotherapy Associate Practitioner (non-qualified, band 4) posts created. Key roles of the PAPs:
¨ Perform basic respiratory assessments and provide treatment/advice.
¨ Deliver ERAS early mobilisation seven days a week.
¨ Carry an independent caseload of non-complex surgical patients, including assessment on day one post-operatively.
¨ Assist in the delivery of individualised rehabilitation sessions for long term patients.
¨ Supervise exercise programmes with long term patients.
(Graphics indicate service change and RaCI pathway)
þ Approximately 110 hours of senior physiotherapist time released in the first six months, enabling development and delivery of RaCI pathway
þ Over 90% compliance with all elements of NICE CG83
þ Increased functional independence of elective surgical patients on discharge from ICCU (mean Modified Rivermead Index (MRMI) 26.4 vs 19.6)
The recruitment of Physiotherapy Associate Practitioners represents a relatively small financial investment. However, it has facilitated a restructure of the physiotherapy team, allowing optimisation of resource allocation to different ICCU patient groups.
Given the current financial constraints on NHS services, this project represents a unique and practical approach to achieving NHS England’s recommendation for safe, sustainable staffing with “the right staff, with the right skills, in the right place, at the right time” (National Quality Board 2016).