Rehabilitation in patients admitted to intensive careBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3921 (Published 16 October 2009) Cite this as: BMJ 2009;339:b3921
- Paulo S S Beraldo, postgraduate rehabilitation sciences
The number of patients who survive after a stay in the intensive care unit (ICU) is rising.1 After leaving the ICU they continue to experience the effects of their primary illness and of interventions they received, and they have higher mortality rates and longer physical and psychological recovery times than the general healthy population.2 Only 49% of patients treated in the ICU for acute respiratory distress syndrome return to work a year after leaving hospital.2 Family members also experience psychological disturbances.3 Thus, these patients represent a financial and social burden that extends beyond their initial illness.
Little research has been published about long term management in these patients: one randomised controlled trial,4 a clinical summary,5 and a few protocols. The trial’s results suggested that rehabilitation started after discharge from the ICU could improve physical state at six months.4
In the linked study (doi:10.1136/bmj.b3723) Cuthbertson and colleagues report a randomised controlled trial and cost effectiveness analysis of a nurse led intensive care follow-up programme aimed at improving physical state and quality of life 12 months after discharge from the ICU.6 About 80 centres in the UK have already adopted this practice, which has yet to be validated. The authors reported a 33% dropout rate and no improvement in any of the physical and non-physical outcomes. No subgroup, stratified by severity of illness, chronic comorbidity, and length of stay in ICU, benefited from the intervention. Less than half the patients attended follow-up consultations with family members. Furthermore, the follow-up programme was not cost effective, with average additional costs of £2316 (€2576, $3803) in the treatment group. The authors suggested that contamination between the intervention and control groups, and the timing of the intervention might explain the findings, but what other reasons could account for the disappointing results? And in the absence of evidence, how can we improve outcomes in patients who have survived the ICU?
Evidence about such patients is difficult to obtain, even after discharge, for several reasons—for example, the challenge of defining syndromes and diseases, heterogeneity of patients, multiplicity of interventions, barely measureable outcomes, and lengthy follow-up, which increases the loss of patients and need for resources.7 8 Also, patients are recruited solely from ICU irrespective of their clinical state on admission, which underscores the need to look at how we define critical illness and how we manage these patients, inside and outside the ICU.9
Accepting that critical illness begins and often ends outside the ICU is a good start.9 The ICU team should not be restricted to the unit and should, in addition to treating the primary condition, participate in preventing and rehabilitating potential sequelae before, during, and after the ICU admission. Perhaps Cuthbertson and colleagues’ study did not find any differences because the intervention was given exclusively to patients who were discharged from the ICU. It appears, in fact, that rehabilitative interventions begun in the ICU yield, in the short term, better outcomes. A randomised trial of critically ill patients on mechanical ventilation who were given physical exercises and early mobilisation during interruption in sedation had improved functional capacity, at least until discharge from hospital.10
Interventions should aim to not only improve morbidity and mortality in the ICU but also quality of life and future longevity. This optimisation “package” should also consider the future caregivers and families of ICU survivors, who need to participate in decision making and accompany the patient during ICU admission while receiving guidance and instruction about the next steps. Caregivers could also benefit from interventions aimed at preventing future psychological sequelae.3
While new evidence is emerging, it is an opportune time to examine current models of care in the ICU. Successful implementation of the “package” will need to take into account factors such as opportunity, intensity, frequency, and length of application. In the absence of randomised evidence we should consider the usefulness of other research designs—for example, observational or even ecological studies.11 12
Cite this as: BMJ 2009;339:b3921
Competing interests: None declared.
Provenance and peer review: Commissioned, not externally peer reviewed.