Authors (including presenting author) :
Poon ST (1), Lo CY (2), Lee WY (1), Ho KM (1), Tang PY (2), Gordon Choi YS (1), Philip Lam KN (2), Winnie Wen TP (1), Joynt GM (1)
Affiliation :
(1) Intensive Care Unit, Department of A&IC (ICU), Prince of Wales Hospital, (2) Intensive Care Unit, Department of A&ICU(ICU), North District Hospital
Introduction :
There are 3 ICUs located in NTEC. PWH ICU is responsible for taking care of the most complex cases, including elective post-operative patients such as cardio-thoracic, specialist vascular and tumor excision, while NDH is responsible for less complex post-operative cases. Because of manpower and structural constraints, complex cases, often requiring multi-disciplinary care can only be managed at PWH ICU. PWH long-stay cases increase the bed occupancy-rate of the ICU, and increase the risk of OT cancellation, consequent on bed unavailability.
From 2017, PWH ICU recognized the presence of a number of long stay patients requiring ventilatory support. Over this period the OT cancellation from lack of ICU bed-availability increased from 10% to nearly 50%. A collaborative model of care between between two Cluster ICUs (PWH & NDH), was developed and implemented in 2018 4Q, with the objective of providing dedicated rehabilitative services at NDH to improve patient outcomes, while reducing the number of long-stay patients in PWH ICU, and ultimately reducing the number of OT cancellations in PWH.
Between 2017 - 2018, PWH ICU recognized the presence of a number of long stay patients requiring ventilatory support. Over this period the OT cancellation from lack of ICU bed-availability increased from 10% to near 50%. The development of collaborative model of care between cluster ICUs was developed and implemented in 2018 4Q, between two ICUs (PWH & NDH), with the objective to provide dedicated rehabilitative services at NDH to improve patient outcomes, reduce the number of long-stay patients in PWH ICU and ultimately reduce the number of OT cancellations in PWH.
Objectives :
1) To promote specialist early mobilization, and rehabilitation of ICU patients in NDH ICU, including the transfer of appropriately chosen patients from PWH ICU to NDH ICU
2) To reduce the number of long stay patients in PWH ICU
3) To ultimately decrease the number of resource related elective OT cancellations in PWH
Methodology :
From 4Q 2018, ICU patients in PWH requiring early rehabilitation services were transferred to NDH ICU. When ready for NDH ICU discharge they were transferred back to PWH general wards under the care of their parent team.
Selection Criteria:
1) The patient’s acute problem/illness has been stabilized, and specialist care under a resident PWH team/s was no longer required.
2) It was anticipated that the patient will need prolonged weaning, or rehabilitation ( > 10 days) prior to discharge, and that outcomes could be improved by the specislist rehabilitative care program.
A patient/family satisfaction score was also collected via a survey with 5-point Likert response scale to evaluate the patient experience of the program, and perception of effectiveness.
Following program initiation, the number of ICU patients and patient days transferred to NDH from PWH, and survival and discharge to home status of transferred patient’s was documented. Finally, the number of elective cancellations in PWH was recorded.
Result & Outcome :
By October 2021 (36 months), 22 patients had been recruited into the program including medical (12), general surgical (4), neurological-surgical (3), orthopedic (2) and cardiac-thoracic surgery (1). The survival rate of transferred patients was 77%, with 68% discharged home.
The total number of NDH ICU bed days utilized by transferred patients was 1305, likely reducing the PWH ICU bed occupancy by long-stay cases by a similar number (mean 1.3 beds per day). The cancellation rate of OT because of no available PWH ICU bed decreased from 50% to 5% in September 2021 as data collected.
The patient satisfaction survey focused primarily on 2 elements - the experience of mobilization, and the overall perception of the program.
(11/15) 73% of patients were satisfied with the start time of the rehabilitation program, (14/15) 93% satisfied with their own progress & the level of exercise prescribed, while (13/15) 86% perceived the frequency of exercise as appropriate.
The highest ranked exercise among patients was bed cycling (44% of responders). This exercise was applied actively or passively depending on the patient’s ability. This was followed by walking with assistance (30% of responders), with the physiotherapist and nursing staff using a specific assistance device. The third (13% of responders) was standing on Sara Combilizer, which can facilitate standing with different angles.
Overall patient/family perceptions related to the program & the transfer between 2 ICUs are explored. 60% of patients responded that the presence of relatives may encourage their exercises. Patient's experience of pain during rehabilitation was explored, although 66% of patients experienced pain during rehabilitation, only 20% of patient expressed that they wanted to quit the program. Half of the patients (52%) stated their transfer from PWH to NDH was smooth, while 48% of the patients responded that they felt neutral regarding the clarity of explanation received about the program and the process of transfer.
The program achieved positive outcomes in terms of patient satisfaction with key aspects of the rehabilitation program, and served to maximize the use of ICU beds within the NTEC. Patients do experience pain, however it was not associated with a desire to quit the program and is not a major obstacle to the mobilization. Patient relatives may play an important role to the rehabilitation program. There is room for improved communication with patients/families, particularly in providing precise and clear information regarding the rehabilitation program and the process of transfer.
