In the current financial climate, more than ever, there is an interest in ‘value for money’ healthcare. Given the amount spent per day on critically ill patients, it is not surprising that there is growing interest in the quality of life and functional ability of those who survive critical illness. As a critical care professional, however, there are also personal, moral and professional reasons why there is a need to know the long-term outcomes of the great efforts we invest. Patients also deserve answers to questions such as ‘will I ever go back to work?’‘When will I be able to walk unaided?’‘When will I get back to eating and sleeping normally?’ as well as the obvious ‘Will I survive?’ These will also be of concern to carers, family and friends.
Kelly and McKinley (2010) have set out admirably to add to current understanding of recovery from critical illness, specifically addressing self-reported quality of life amongst survivors at six months after discharge. However, it is important to consider the context and setting of the study to enable a consideration of what implications this study has for them at a local level.
Critical care is a diverse speciality and, whenever a study focuses broadly on critically ill patients, it is important to appreciate this diversity in order to be discerning about the application of findings in patient subsets and sub-speciality areas. Within the UK, critical care has been divided in to two levels, level 2 (high dependency care) and level 3 (intensive care). However, this model has not been adopted internationally. Hence, in some instances, what may be referred to as ‘intensive care’ in Australia or North America, for example, might well be classified as level 2 (high dependency care) in the UK.
Further detailed categorisation delineates medical, surgical, neurological and cardiothoracic intensive care and high dependency care. Within these, the diagnoses, ages, co-morbidities and lengths of stay create a very diverse population to study from the perspective of recovery and quality of life during recovery.
Kelly and McKinley’s (2010) study presents a measure of the quality of life according to a validated tool at a point in time for a small sample of diverse patients. In doing this, it clearly highlights the need for further studies that focus on sub-groups of critically ill patients: for example, those who have stayed longer than the average of five days, those who have higher APACHE II scores and those who remain in hospital for prolonged periods after leaving the critical care environment before going home.
The recent guidelines on rehabilitation after critical illness published by the National Institute for Health and Clinical Excellence in the UK (NICE 2009) advise clinical staff to identify those at risk of long-term physical and non-physical problems and who therefore require rehabilitation. This sets up a useful, if non-empirically validated, framework for assessing, referring, treating as well as researching recovery from critical illness.
Kelly and McKinley (2010) very appropriately advocate early follow-up for the critically ill – within the first three months after discharge. However, this recommendation focuses on follow-up after discharge from hospital. This continues to emphasise and isolate follow-up services in the rehabilitation process. If the point of follow-up is to assist with rehabilitation, rehabilitation should commence before leaving critical care and continue immediately afterwards in the ward environment as well as after leaving hospital. This requires greater integration, communication, inter-professional working as well as funding. This, in a nutshell, encapsulates the challenges currently faced by clinical staff attempting to deliver on the guidelines published by NICE (2009).
A valuable lesson clearly exists within the paper with regard to the recruitment of patients who have been critically ill and probably a wider population of patients discharged from hospital. This is a lesson I have also learned and have factored into my own research. Kelly and McKinley recruited participants by telephoning them at home. It appears that two had died between leaving hospital and their call from the researchers. This is clearly unnecessary stress for the family of the deceased and raises the question of whether the patients’ family doctor could have been a useful resource for identifying patients who have died at home first.
However, despite the valuable contribution of this study, it is important to acknowledge its key limitations. First, the sample size is small and is drawn from a single centre, meaning that any statistical tests undertaken offer little prospect of valid and meaningful outcomes that apply to other populations. The authors state that they found no ‘relationships’ between SF-36 scores and admission diagnosis, gender, age or length of stay. It would be interesting in a larger sample to see multiple regression analysis to explore more fully these relationships, especially those between SF-36 scores and added variables such as high APACHE, and extended lengths of stay. It is interesting that there are considerable differences in the category values reported in Kelly and McKinley (2010) and studies they cite with much larger samples that may have suffered lesser effects from outliers in a small sample. Similarly, the fact that they had to perform ‘logarithmic transformation’ to achieve a normal distribution for length of stay raises questions about how this sample may compare with other populations in the various critical care units.
Researchers and practitioners in the UK have in the NICE (2009) guidance a useful framework for rehabilitation, but one that can be frustrating because successful implementation and evaluation requires additional real-term resources. However, merely the mindset of assessing each and every patient and considering their short-, medium- and long-term goals offers the prospect of a step change in the way patients are treated after surviving critical illness. This also offers the prospect of extensive data on where the greatest challenges and opportunities are in returning the critically ill to functional health and quality of life.