The background to rehabilitation after critical illness (RaCI), is that there are largely only negative trials of it’s effectiveness (links here, here and here). There is a positive trial however the intervention there was self-administered and continued post hospital discharge.
The evidence for rehabilitation within the ICU is better (more positive), and this makes sense given that delaying an intervention until after the damage is done is maybe not the way forward. Nevertheless, NICE guidance tells us that, as well as performing seemingly endless assessments, at risk patients after ICU discharge should receive an ‘individualised structured rehab programme’. In addition, the guidelines for the provision of intensive care services produced by the FICM and the ICS tell us that:
‘Patients receiving rehabilitation are offered a minimum of 45 minutes of each active therapy that is required, for a minimum of 5 days a week, at a level that enables the patient to meet their rehabilitation goals for as long as they are continuing to benefit from the therapy and are able to tolerate it’*
The trial was negative. Or was it? The patients liked it, despite not getting any happier, stronger, or improving their function. As the authors write in their conclusion
“[These data] illustrates how improvements in care that matter to patients can occur without measurable effects on biomedical outcomes”.
Now I’m all for that, but if you were a commissioner having to foot the bill would you? (£700/patient)
Another interesting feature of this paper was the use of the Rivermead Mobility Index, which I’d never come across before. Essentially, it’s a list of escalating physical activities, from turning over in bed to running 10m in 4 seconds. You get a point for each you can do. There’s a ‘scorecard’ here, and I would encourage you to look at it now, and consider what score would be acceptable to you at ICU discharge, hospital discharge and at 3 months. Only once you’ve done that, consider what this UK paper tells us about the functional state of our patients.
I was expecting to be a bit depressed, but actually at 3 months I think the (physical) outcome is not too bad (so long as you’re in the top 50%) – better than I thought would be acceptable to me in any case.
So we’re left with people who do need help (functional state at ICU discharge was depressing), but with recommendations for an intervention showing no benefit. Maybe in the short term making them happier will suffice? Or maybe putting more effort into rehab in the ICU, starting from the hour of admission, is where we should focus our efforts (and cash)?
*(as a complete aside it's interesting that the correct 'dose' is 45 not 40 minutes, but 5 not 7 days is OK!).