Much has been written regarding the negative impact both physically and psychologically as a result of a period of critical illness. From a physical perspective, muscle wasting and weakness are common and are more likely with prolonged periods of mechanical ventilation. In fact, muscle mass has been shown to decrease at a rate of between two and four per cent per day during the initial two to three weeks of ICU admission (Helliwell et al 1991; Brower, 2009) although in some patients the loss is as much as six per cent per day (Bloomfield, 1997). This physical morbidity is associated with prolonged weaning from mechanical ventilation, longer ICU and hospital stays and increased mortality levels. In the longer term, this physical morbidity can leave a lasting impression with recovery taking a number of months or even years. An observational study by Herridge et al (2011) found persistent functional disability over five years following discharge from critical care in a group of ARDS patients. Prolonged ventilation in critical care is also associated with impaired health related quality of life up to three years after discharge, even when patients are living independently at home (Combes et al 2003).
From a psychological perspective, the prevalence of anxiety and depression in critical care survivors have been demonstrated at 22-47 per cent and may still be present nine months following hospital discharge (Sukantarat et al, 2007; Scragg et al, 2001). Levels of cognitive dysfunction such as problems with memory, attention and problem solving have been reported to be as high as 75 per cent and still present at one year following critical care discharge (Hopkins, 1999, Jones et al, 2006). There is also an incidence of post traumatic stress disorder (PTSD), with levels identified as ranging from 15-51 per cent in survivors of critical illness (Scragg et al, 2001; Jones et al, 2001). This psychological impact is not isolated solely to patients, with a survey of relatives identifying high levels of anxiety and depression (Young et al, 2005) as well as PTSD as high as 49 per cent (Jones et al, 2004).
In the UK it is estimated that one or two per cent of the total NHS hospital budget is spent treating critically ill patients (Bion, 1995). What is not fully understood is the longer term impact and subsequent cost on the wider health and social care services. An analysis of critical care survivors at the point of hospital discharge has shown a physical function at only 50 per cent that of an aged matched healthy population (Benington et al, 2011), and suggested only 40-60 per cent are functionally independent at this time (Schweikert et al, 2009). This level of debilitation places high demands on secondary care services such as GP’s, social care services, community rehabilitation and welfare benefits. Despite this, support and follow up after hospital discharge remains rare with only 30 per cent of UK based intensive cares providing follow up clinics for survivors of critical illness (Griffiths, 2006).
There are approximately 100,000 admissions to ITU per year in England of whom circa 75,000 leave hospital. 17,500 of these ITU admissions stay in the Unit for longer than five days. About 35,000 of these patients stay in hospital for more than 17 days and about 17,500 for over 35 days. These are significant lengths of stay in both ITU and hospital that have major cost implications both in terms of hospital services (and resources) and community costs post discharge.
Improving outcomes and reducing costs
Early measures
The evidence base for early rehabilitation within critical care is growing. The term early mobilisation in the ICU refers to focused interventions that begin as soon as hemodynamic and respiratory problems have stabilised, frequently within the first few days after ICU admission. Numerous studies have demonstrated rehabilitation to be safe, feasible and an important measure in improving both short term outcomes and long term recovery in critical care patients. Specifically, early and structured rehabilitation programmes have been shown to decrease both ICU and hospital length of stay (LOS), reduce incidence of delirium (Schweikert et al 2009; Needham et al, 2010) and lead to improvements to both respiratory and peripheral muscle strength (Chiang, 2006).
In a study completed in a North American intensive care unit, Morris et al (2008) demonstrated the implementation of an early rehabilitation programme to be associated with a reduction in both mean ICU (1.4 days, P<0.05) and hospital LOS (3.3 days, P<0.01). Following the introduction of a quality improvement programme for early rehabilitation programmes, Needham et al (2010) demonstrated a similar reduction of 2.1 days on ICU and 3.1 days in hospital. This positive impact of early mobilisation is even more pronounced when specifically looking at those with longer stays on ICU. McWilliams and Westlake (2011) analysed the impact of structured rehabilitation for patients with a LOS of > 5 days within a UK based level 3 intensive care. Over a three year period following introduction of the programme they demonstrated a reduction of 6.2 ICU days and 31.8 days in hospital in response to the structured rehabilitation programmes. These studies support the theory that early mobilisation whilst still in intensive care units and the associated improvements in global muscle strength, alongside improvements in cardio respiratory fitness can help to facilitate weaning and thus reduce ICU LOS.
Perhaps more importantly, alongside a reduction in ICU LOS, McWilliams and Westlake (2011) demonstrated a higher level of mobility at the point of critical care discharge. Specifically, this meant the average patient was now standing and stepping to a chair at the point of ICU discharge in comparison to data obtained prior to the introduction of structured rehabilitation programmes which had shown an average mobility level of being hoist dependent for all transfers from the bed to a chair at the same time point. This meant that the patients analysed were not only being discharged sooner but also more physically able. This is particularly the case when the early rehabilitation is led by physiotherapists (Garzon-Serrano et al, 2011). In real terms a patient who is more mobile on return to the ward is also likely to spend shorter periods in hospital as they will be significantly further in their recovery period (McWilliams and Macdonald, 2011), as well as being more functionally independent at the point of hospital discharge (Schweikert et al, 2009).
Conclusion
From the minute a patient is admitted to intensive care the body is in a state of muscular and cardiovascular decline. This decline continues on a daily basis, with longer admissions leading to higher levels of muscular weakness, patient dependence and poorer outcomes. Historically the mainstay of treatment has been the physiological stability and recovery of patients, supported by period of mechanical ventilation and bed rest. With new technologies and developments within medical management more patients are now being admitted to and surviving periods of critical illness. However, the physical and psychological sequelae of critical illness can leave a long lasting legacy in terms of long term health, quality of life as well as a costly impact on both health and social care services. This begins with the daily cost of intensive care due to expensive drug therapies, technology and an array of specialist staff from a variety of professions to name but a few. On discharge to the ward, patients often present with significant physical and psychological rehabilitation needs requiring ongoing intervention from various members of the MDT. At the point of discharge from hospital, patients will often require ongoing rehabilitation either in specialist units or in their own homes. This whole journey can have a significant impact on the income of families, with 1/3 of families losing their main source of income and 1/3 losing the majority of their savings, whilst it frequently takes 9-12 months for ICU survivors to return to employment (Eddleston, 2000).
It is fair to say that to maximise the impact of early and structured rehabilitation programmes within intensive care additional investment is required to ensure an adequate number of appropriately trained staff and appropriate equipment is available. This would however prove to be a sound investment, as aside from significantly improving patient outcomes and quality of life, programmes of structured and early rehabilitation can have significant potential for cost savings. Firstly, early mobilisation has been demonstrated to reduce ICU LOS. In reality, although the cost per case may be reduced these costs may still exist as another patient is undoubtedly admitted into the empty bed. Benefits may still be observed due to a reduction in the number of occupied or so called ‘blocked beds’. This would subsequently reduce the potential for any cancelled surgical activity, or a reduced pressure to discharge patients who perhaps aren’t quite ready or during unsocial hours when a bed needs to be created, both of which can lead to increased mortality levels (Duke et al, 2004).
Speaking in general terms, even small changes in terms of LOS can have a huge impact on ICU costs. Assuming a critical care bed costs in the region of £1700 ($2.228) per day, on a relatively small unit with 250 admissions per year, a mean reduction of 1.4 days as seen by Morris et al (2008) would equate to a cost saving of almost £600,000 ($940.674) or an additional 350 free bed days within critical care.. When you next consider in the ward environments, patients who are less debilitated will require less intensive rehabilitation and are less demanding on the nursing staff. Coupled with this, they will also be ready for discharge much sooner than a patient who is bed bound and dependent for all care, and as such post ICU costs and bed occupancy will also decrease. The higher level of functional independence at hospital discharge may also reduce any burdens felt on community rehab and support services. When compared to the cost of an additional physiotherapist and appropriate equipment required in order to deliver these programmes the additional resource would seem extremely economically justified to generate cost savings in the longer term. The key message is prevention or at least limitation is better than cure.
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