Following Intensive Therapy Group (FIT) group

Summary

A conditioning class for those who have been in intensive care provides a group-support environment for recovery through activity and advice.

People who experience intensive care stays, whether pre-planned or following crisis, experience deconditioning beyond the average fallout from illness.

65.1%
of the patients showed a significant improvement in physical function both after the class.

Description

Approximately 179,271 people spend time in critical care units in England, Northern Ireland and Wales each year, the majority surviving to be discharged home.1

Research has shown that critical illness has a significant effect on patients long after they are discharged from critical care. Many patients experience weakness, loss of energy, anxiety, depression, post-traumatic stress (PTS) phenomena or a decrease in cognitive function, to name a few.2

Therefore, in order to maximise an individual’s potential to return to their previous function, rehabilitation should start as early as clinically possible and continue with a tailored rehabilitation programme during their ward stay through to discharge home as indicated.

The service was set up in 2010, following a visit to the McWilliams programme in Manchester Royal Infirmary, to take those post ITU patients who are medically stable, and those recently discharged home following an ITU admission. The group individuals are assessed and given reconditioning programmes, talks and peer support through their recovery. The service is integrated into the care plan to help with rehabilitation as soon as possible.

Aims:        

The group has been running for 6 years and provides peer support to those who have experienced critical illness and are facing a long rehabilitation.

Patients are assessed using specific evidence-based tools:

  • Hospital Anxiety and Depression (HAD) scale3
  • The Short Form (36) Health Survey SF 36 4
  • Incremental Shuttle walk test5
  • 6 minute walk test 6

It links into the ITU Rehabilitation Network and Follow-up clinic for on-going communication regards the patients discharged home.

                                                             

Initiation and implementation

Following a visit to a similar service established in Manchester Royal Infirmary, a business plan for the development of a service tailored to meet the needs of local patients was developed. Additional funding was not available, so the manager diverted money from the internal budget, calculating the costing of a number of individual patient slots that could be utilised for this patient group, to provide the time resources for individual assessments and delivery of group session therapy.

Where possible, patients are introduced to the concept of the reconditioning FIT group as early as possible. Once considered capable, eligible patients are encouraged to attend as part of their in-patient recovery programme and then to continue to attend after discharge home. The programme also accepts those who have been on intensive care elsewhere.

Each group comprises 8 – 10 people led by a Band 6/7 and supported by a Band 5 or a Band 3, depending on staffing availability.

In addition, the team benefits from input by an OT, a dietician and the ITU follow-up sister, who supports management of post –ITU experiences, such as sleep hallucinations, loss of hair, weight gain etc.

Individuals who have reconditioned through the FIT Group are signposted to leisure activities such as gyms, Otago exercise groups, and classes in the community. They are also referred to Pulmonary Rehabilitation, if appropriate.

The FIT Group provides, in a group environment:

  • Tailored exercise programmes: functional and relaxation,
  • Self-management and coping strategies
  • Education:  dietician, OT ITU Follow-up Sister*
  • Peer support which has been invaluable – (some patients have been helped by the rolling programme, and seeing patients that are further on in their recovery).

 

 

Quality

Data collection has been over a period of 3 years, although there have been no regular systems in place for regulating input. Unfortunately this is service is not yet commissioned, therefore there are other services that have higher priority for use of resources. 

Patient satisfaction surveys have helped with the progressive development of this unique service as the patients and their families have highlighted areas of need, for example, earlier intervention, and some specific topics for talks from our ITU follow-up sister. The vast majority of patients report a definite benefit to attending the class and from the data analysed 73% are able to reach their pre-admission level of function. The collated data shows improvements physically, psychologically & socially for patient once completing the class, and also after 3 month follow up.

’When I started the programme I found any exercise very hard but by the end of it I was finding it much easier. The physical improvement was tremendous.’

‘I feel that I have regained muscle strength quicker than if I had just been left to my own thing. The sessions did encourage me to do the exercises at home also.’

‘As a relative I think it is very important that sessions like these are run, it helps confidence, and stretches their ability to see that exercises and advice from the various sessions has been a great help.’

‘The help and advice given by the Follow-up team has been invaluable with the FIT programme being the icing on the cake.  I have found rehabilitation very beneficial.’

‘A huge thank you to everybody who helped get me back on my feet’

One of our recent patients was deemed unfit for surgery, but improved his physical condition to the point where he was accepted by the surgical team once he completed the class.

The project has meant that there are fewer barriers to continuing rehabilitation for these patients. Prior to the programme, these patients would be referred to community, with waiting times being up to 4 months on occasion. Rapid access to rehabilitation can only be beneficial for our patients. Many of our patients have exceeded their own expected timeframe for returning to work and / or their previous level of function.

We use several outcome measures to evidence this. Namely the 6 minute walk test, SF36 questionnaire, Hospital Anxiety & Depression scale, and an in house post class questionnaire.

Patients on average showed a significant improvement in physical function both after the class (65.1% have improvement) & at 3 months follow up (49% have improvement):

 

6MWT

Averages

Pre

Post

FU 3/12

AVE Distance (m)

182.9

302.1

272.6

 

N=21

 

N=12

Significant improvements physically, psychologically & socially can also be seen from the SF36 data:

SF36

 

Post % progress

3/12 FU % progress

Physical Functioning

21.7%

29.2%

Physical Health

8.7%

19.8%

Emotional Stresses

13.0%

27.8%

Energy / Fatigue

13.5%

15.8%

Emotional Wellbeing

8.0%

6.5%

Social Functioning

12.5%

18.8%

Pain levels

10.0%

7.9%

General Health

9.9%

6.9%

 

N=23

N=12

In addition to this, patients are also showing a very significant reduction in Anxiety & Depression scores as detailed below. Minimal important difference for the HADS anxiety and depression score is referenced to be 1.32 and 1.40, respectively.

 

HADS

 

Anxiety

Depression

Averages

Pre

Post

FU

Pre

Post

FU

Score

8.4

5.2

5.5

8.1

5.6

4.8

Change in score

 

-3.2

-3.1

 

-2.5

-3.2

   

N=23

N=13

 

N=22

N=13

 

As you can see, data is limited on 3 month follow up.

23 Forms were returned,  Summary of results is detailed below.

 

Specific feedback included these quotes:

‘I enjoyed the support & conversation with the staff who gave me excellent advice & encouragement’ 

‘A big thank you! Please continue to do good work for other patients in the future’

Pre course information

Session Length

Benefits of group sessions

Education content

Useful education sessions

Yes (N=22)

Just right (N=22)

Yes (N=22)

Easy to understand (N=20)

Breathing (N=8)

No (N=1)

About right (N=1)

No (N=1)

 

Relaxation  (N=6)

   

Supported (N=17)

 

All (N=5)

   

Others making progress (N=4)

 

Pacing (N=4)

       

Exercise (N=2)

       

Diet (N=2)

 

 

 

 

 

Additional information

Intensity

Benefits attending class

Pre-admission level reached

Changed habits

Diet (N=3)

Just right (N=19)

Yes (N=22)

Yes (N=14)

Yes (N=18)

Return to work (N=1)

Too easy (N=1)

Improved confidence (N=7)

No (N=5)

No (N=2)

Diabetes (N=1)

Too hard (N=1)

 

 

 

 

OK (N=1)

 

 

 

Cost and savings

This service has not been evaluated with regards to delivering a cost-saving impact.

The funding has been absorbed by the physiotherapy department through analysis of workforce activity with this group of patients and also using the Manchester model to introduce a cost-neutral, patient focused innovative approach to rehabilitation.

The main impact data collected has focused on quality of life and rate of recovery of the individuals. Patients analysed with complete sets of data have shown improvements in physical, psychological and social objective markers, although the number of results is insufficient to use for clinically relevant statistical analysis. Improvements are outlined above.

It is anticipated that improving general functioning for these patients will reduce the burden on social care, and the number of visits to GP and hospital services. Therefore overall a cost-effective service although this is difficult to evidence.

What did you learn?

  • We have shared the findings of the programme with the regional critical care network.
  • The initial set up was for patients to attend post discharge from hospital, but we have been able to get some patients through earlier - those medically fit on the wards.
  • We would have like to pilot the project for longer to try and gain appropriate funding. The trial was done out of our normal establishment, and due to the overwhelming success and positive feedback, was extended to a permanent fixture without the opportunity to present with pilot for funding.
  • The Respiratory Service is recruiting for permanent staff and the intention is that the group will be run by a Band 6 supported by a Band 4 on a more permanent basis.

Future Work

  • After the success of the FIT group, the department has now extended to developing of a Respiratory Exercise group (REG) for those with dysfunctional breathing.
  • The Respiratory Exercise Group provides Pilates, breathing and functional exercises for those progressing from 1:1 sessions to developing a more functional aspect of their breathing retraining.

Relevant contacts and resources

  1. UK Intensive Care National Audit and Research Centre (ICNARC) Annual Quality Report 2014/15 for adult critical care. https://onlinereports.icnarc.org/Reports/2016/4/annual-quality-report-201415-for-adult-critical-care
  2. NICE clinical guideline 83 – Rehabilitation after critical illness: https://www.nice.org.uk/guidance/cg83/evidence/full-guideline-242292349
  3. The Hospital Anxiety and Depression Scale http://www.ncbi.nlm.nih.gov/pubmed/27153046
  4. The Short Form (36) Health Survey SF 36 University of Stirling Impact measurement: http://www.measuringimpact.org/s4-sf-36
  5. Incremental Shuttle walk test, The 2014 Research Excellence Framework (REF). http://impact.ref.ac.uk/CaseStudies/CaseStudy.aspx?Id=19096
  6. 6-minute walk test American College of Rheumatology; http://www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Six-Minute-Walk-Test-SMWT