Update on NICE guidance CG83 Rehabilitation after Critical Illness.

In 2009 the Nation Institute for Health and Clinical Excellence (NICE) published their guideline on Rehabilitation after Critical Illness. Over one hundred thousand people spend some time in a critical care unit every year in the UK (NICE 2009). Until recently there was little understanding of the longer term consequences of having a critical illness or what actually happens to patients once they are discharged. Even less thought was given to the consequences for families of the patients. Therefore the recognition of the physical and non-physical consequences of critical illness and the production of the NICE CG83 to guide management of patients was very welcome.

NHS Evidence was launched in 2009 and bought together 34 specialist electronic libraries formally administered by the National Library for Health. The BACCN has ensured that critical care nursing is represented on the appropriate section of NHS Evidence, this being NHS Evidence-surgery, anaesthesia, peri-operative and critical care. Part of the remit of NHS Evidence was to provide an annual, detailed update of literature published since the original release of the NICE guidelines. It is very important to identify what factors contribute to physical and non-physical problems for patients following critical illness and what can be done to prevent or manage these problems. BACCN were invited to take part in the update. A total of 29 articles were selected for review and these were distributed to a team of reviewers. Four articles were reviewed with direct relevance to nursing and the full update can be found at http://www.library.nhs.uk/THEATRES/ViewResource.aspx?resID=345330

Not surprisingly duration of sedation, duration of ventilation and length of stay on ICU were associated with depression following critical illness ( Davydow et al 2008). This review concentrated on patients with a diagnosis of Acute Lung Injury (ALI) or Acute Respiratory Distress Syndrome (ARDS). It is uncertain whether the results of the review are specific to ALI/ARDS or critical illness in general but the findings show that Post Traumatic Stress Disorder (PTSD) remains high at 1 year post ALI/ARDS and can still be present at 8 years. The presence of depression and PTSD were associated with lower quality of life. Finding means of reducing length of stay through the use of best practice is an important issue for all critical care practitioners.

Wikehult et al (2008) studied burn injured patients and found fear is associated with Post Traumatic Stress Disorder (PTSD). Nurses should minimise moments of fear and pay extra attention to verbal and non-verbal cues of fear. Fear in this study was mainly associated with not making it. Although the authors make explicit the limitations of research I would suggest the relationship between fear and PTSD is important in the prevention of PTSD. How many times have any of us walked into an ICU and seen terror in patients’ eyes. This an interesting article which has limitations but also has important implications for nurses and other practitioners regarding minimisation of frightening experiences during ICU stay.

Hofhuis et al (2008) specifically studied the perceptions of patients regarding nursing care. Three important factors emerged in relation to supporting patients:

Providing patients with information and explanation
Placing the patient in a central position i.e. seeing them as a human being.
Personal approach by nurses

This study should remind nurses of the importance of information giving and seeing the patient as a human being. These fundamental elements of support may get forgotten about in the hi-tech environment of the ICU.

Patient diaries have become a popular method of recording events for patients whilst in ICU. Engstrom et al (2009) conducted a study regarding the use of patient diaries and the findings of this study highlight that the reading of diaries by former patients is not without emotional and psychological consequences. Nurses need to be aware of this when implementing diaries and perhaps they should always be used in conjunction with ICU follow up.

The updated literature for NHS Evidence reminds us that as nurses, and other practitioners, our actions and the way we provide support for patients has a profound effect on their rehabilitation.

References

Davydow D.S. Desai S.V. Needham D.M. Bienvenu O.J. (2008) Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review. Psychosomatic Med 70(4) 512-519
Engstrom A. Grip K. Harmen M. (2009) Experiences of intensive care unit diaries: “touching a tender wound”. Nursing in Critical Care 14(2) 61-67.
Hofhuis J.G. Spronk P.E. van Stel H.F. Schrijvers A.J. Rommes J.H. Bakker K. (2008) Experiences of critically ill patients in the ICU. Intensive and Critical Care Nursing 24(50 300-313
NICE (2009) Rehabilitation after critical illness. Clinical Guideline 83, www.nice.org.uk
Wikehult B. Hedland M. Marsenic M. Nyman S. Willebrand M. (2008) Evaluation of negative emotional care experiences in burn care. Journal of Clinical Nursing 17(14) 1923-1929.

Vanessa Gibson
Professional Advisor
BACCN National Board