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Critical Care Follow Up Clinics Are they effective?
Charlotte CarvellDavid Owen
Introduction
• Critical Care – evolving……
Introduction
• ICU patients - sickest + need the most support
• Many survivors experience a range of physical and psychological problems
Introduction
• Problems don’t stop at the point of discharge
• Problems often complex and not easily suited to current follow up systems
• Problems are often not recognised or treated.
• Patients can easily be “lost” in a sometimes hectic system
Introduction
• Nice guideline 83 – suggests that rehabilitation strategies for these
patients could offer many benefits…• reducing length of hospital stay post ICU• reduce readmission rates• reducing use of primary care resources • expedite patients return to their previous level of
activity.
Introduction
• A Critical Care Follow Up clinic introduced in Morriston Hospital, in an attempt to address some of these issues.
The Clinic
• Critical Care Consultant, Band 7 nurse, Physiotherapist
• Dedicated secretarial support• Approx. 4 patients seen / clinic / fortnightly• Patient selection – “very loose”• 45 minutes / patient• Not funded• No formal Out Patient facilities / support
Aim of Clinic
• Holistically review / investigate and manage needs and problems– Co-ordinate Care– Establish suitability for physiotherapy based
rehabilitation (and RCT) – Give advice e.g. smoking cessation, weight loss– Discuss the patients recollections and experiences – Enquire about family experiences
• Ask for informal feedback
Study - Aims
• Determine – “effectiveness” of the clinic - numbers and types of
interventions / patients seen– Relationship between LOS and no. of interventions– Relationship between Level of Care and no. of
interventions– Relationship between original problem and no. of
interventions– Which patient groups benefit most?
Methods
• 1 years activity reviewed - Jan 2011 – Jan 2012• Length of time from discharge to clinic appt. • The “type” of patient + their original level of
care• Their length of stay on ICU• The number of interventions made in clinic• Which patients received the most interventions
Results
• 55 patients • Male 32, Female 23• Average age 59.9yrs• 25 Level 2 patients• 30 Level 3 patients
Patient age
0
5
10
15
20
20 30 40 50 60 70 80 90Age
No
. of
pat
ien
ts
Results - Patients
• 27 Medical
• 28 Surgical - 13 elective cases
Results
• Average LOS 18.1 – Average LOS level 2 17.80 days– Average LOS level 3 18.27 days
Length of stay / Level 2
02468
101214
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Length of stay
No
. of
pa
tie
nts
Length of stay / Level 3
0
2
4
6
8
10
12
14
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80Length of stay
No
. of
pa
tie
nts
Clinic Interventions
• 107 interventions made
• 1.95 interventions / patient
No. interventions / patient
0
2
4
6
8
10
12
14
16
18
20
0 1 2 3 4 5
No. of interventions
No
. of
pa
tie
nts
Clinic Interventions
Referral
Investigation
Drug change
Advice
Physio
0
5
10
15
20
25
30
35
1
Interventions
No
. o
f in
terv
enti
on
s
Clinic investigations
'Routine' bloods CXR
TFTs MSU
Inflammatory markers
ECG
0
1
2
3
4
5
6
7
8
1
Investigation
No
. o
f in
vest
igat
ion
s
Other Interventions
• 2 psychiatric referrals were made for PTSD
Is there a relationship between LOS and no. of Interventions?
Relationship between LOS and interventions
0
20
40
60
80
100
0 1 2 3 4 5 6No. of interventions / patient
LO
S in
da
ys
LOS and Number of Interventions
• Regression analysis - a slight positive association with increasing length of stay and increasing number of interventions.
• R square 0.07 / P = 0.046
Is there a relationship between Level of Care and No. of Interventions?
Levels of Care and No. of Interventions
• Level 2 patients - 46 interventions– 1.84 interventions / level 2 patient
• Level 3 patients - 61 interventions– 2.03 interventions / level 3 patient
No. interventions / Level 3 patients
0
2
4
6
8
10
12
14
0 1 2 3 4 5
No. of interventions
No
. of
pa
tie
nts
No. of interventions / Level 2 patients
0
2
4
6
8
10
12
14
0 1 2 3 4 5
No. of interventions
No
. of
pa
tie
nts
Is there a relationship between original problem and No. of Interventions?
No. of interventions / disease class
Cardiac
Respiratory
GI
Miscellaneous
Other infectionGU Trauma
Neurological
0
5
10
15
20
25
30
35
40
45
1
Disease class
No
. o
f in
terv
en
tio
ns
Is there a difference between interventions for surgical vs medical?
No. of interventions for surgical or medical
patients
Surgical
Medical
0
0.5
1
1.5
2
2.5
1
Discipline
No
. o
f in
terv
en
tio
ns
What’s everybody else in Wales doing?
What’s everybody else in Wales doing?
• ICU’s across Wales were contacted
What’s everybody else in Wales doing?• 4/16 – Critical Care Follow up clinics
• Glan Clwyd - nurse led service - patients invited back to the unit
• Nevill Hall – nurse led and diary based
• Wrexham Maelor – medical + nursing led clinic
• Princess Of Wales - cancelled clinic - lack of funding.
What’s everybody else in Wales doing?
• Limited and varied ICU Follow Up services
• No funding.
Summary
• Help co-ordinate care
• Majority required at least 1 intervention and often more
• Patients with longer LOS, who were Level 3 and respiratory appear to benefit most
Conclusions
• ICU Follow Up Clinics appear to be beneficial
• But…..varied and limited in Wales with no funding.
Questions?
Time since discharge
0
50
100
150
200
250
300
350
400
450
500
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55
Patient
Day
s
Comparison of length of stay with level 2 and 3 patients
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
Number of Patient
LO
S in
day
s
Level 2
Level 3
Types of medication interventions
Stopped
Sw itched
Added
Restarted Dose change
0
1
2
3
4
5
6
7
8
9
10
1
Intervention
Nu
mb
er
• Respiratory patients needed the most interventions 32.7%
• Followed by Cardiac (16.8%), Mixed picture (12.2%) and GI (11.2%)
Results
• Average time to follow up from discharge 105 days
• 65% seen in under 3 months
