Supporting community recovery and reducing readmission risk following critical illness in icu survivors

Introduction: Survivors of critical illness experience multidimensional disabilities that include physical, psychological and cognitive decline, social challenges and reduced quality of life. This accumulation has been termed post-intensive care syndrome (PICS) (1), with 25–30% requiring unplanned hospital readmission within 3 months following index hospitalisation(2). Impact is also high for families/carers, especially in social & psychological domains. Post-ICU recovery programs have not been widely studied or adopted despite the scope of these problems. Methods: Listening to and Learning from ICU Survivors and Families/Carers To understand the complexity of ICU survivorship, and reasons for early unplanned hospital readmission, we conducted a mixed methods study involving patients and families/carers (3,4). This involved in-depth 1-2-1 interviews and focus groups with ICU survivors (n=50) and families/carers (n=51). This with a view to informing the evidence-based development of clinically and cost-effective interventions for a new integrated care pathway in Scotland’s second largest Health Board NHS Lothian. For around half our patients a ’complex health & psychosocial needs’ context occurred with multi-morbidity and polypharmacy, significant psychological & mobility issues, problems with specialist aids/equipment and fragile social support prior to critical illness. ICU survivors described inadequate preparation for hospital discharge, poor communication between secondary/primary care, and inadequate support with psychological care, medications and goal setting. Aim, Practice Change Implemented & Timeline: We aimed to introduce a new integrated care pathway providing holistic, multi-disciplinary hospital assessment and improved community support for ICU survivors. Consequently, we secured funding for a 15 month Quality Improvement project starting 1st March 2018. We developed (i) an ICU holistic needs assessment tool to facilitate early identification of ICU survivors at risk of unplanned readmission; (ii) introduced in-hospital holistic needs assessment to identify clinical and psychosocial needs of ‘at risk’ ICU survivors; (iii) developed more formal and quicker communication links between ICU hospital assessment staff and GP’s, community multi-disciplinary NHS locality HUBS, community pharmacies and third sector community social prescribing groups; (iv) facilitated community follow up of ICU survivors at 2 and 8 weeks after hospital discharge. Hi