Rehabilitation framework

This chapter addresses the importance of integrating the process of rehabilitation within the milieu of critical care. A conceptual model will be presented to show how rehabilitation can be organized within the ICU, incorporating the whole of the patient s journey irrespective of their length of stay (LOS) within the ICU. The chapter will focus on those patients who require prolonged mechanical ventilation (PMV), i.e., >21 days and will be presented from a U.K. perspective. Case examples from my own critical care practice will be used to demonstrate how a rehabilitation framework of care impacts upon patient mortality, quahty of care, and ICU costs. Finally, recommendations will be made for future practice. 

Following implementation of the long-term phase of the rehabilitation framework, she was weaned and decannulated within 21 days. Her total LOS in the ICU was 106 days at a cost of 159,000 ( 301,221). She was transferred to the ward and went home 14 days later on an individual pulmonary rehabilitation program. At six months Sarah was back at work full time and has had no further physiological or psychological problems. Appendix 1 shows Sarah s specific rehabilitation and weaning plan. 

Table 3 Sarah s Weaning Episodes Prior to Commencing the Long-Term Phase of the Rehabilitation Framework...

Figure 7 PS level following implementation of the long-term phase of the rehabilitation framework. Abbreviation PS, pressure support.

Following implementation of the rehabilitation framework, May was weaned from MV and decannulated within 21 days. Her total LOS was 72 days at a cost of 108,000 (S204,588). She was transferred to the ward but waited for another 33 days before being transferred to a rehabilitation facility, where she stayed for 21 days. Now, one year later. May lives at home, cares for herself, socializes, and is making good progress. 

The rehabilitation framework implemented in these two ICUs has positively influenced patient outcomes. Figure 10 shows survival, in 2005, of patients who required MV more than 21 days in 3 separate ICUs within SWCCN. Although the patients had similar demographics and clinical characteristics, mortality in ICU C was 57% compared to ICU A and ICU B, where mortality were 24% and 20%, respectively. There are great opportunities for a more formal evaluation of the influence of this rehabilitation framework. 

Introduction of a general rehabilitation framework across all general ICUs to promote rehabilitation as an integral part of intensive care management. 

Once Sarah was placed into the long-term phase of the rehabilitation framework, all active weaning from MV was stopped and the nurse consultant, the lead doctor, and the PT made a comprehensive and holistic assessment. Further advice was sought from the dietician, the speech and language therapist, and the pharmacist. An overall plan was then developed, which included the following ... 

A weaning pathway (Fig. 1) was developed to accommodate those who might be weaned from MV. A rehabilitation framework (Fig. 2), which focused on whole body rehabilitation, also enabled some patients to be weaned and discharged home. ICUs identified core teams of... 

Figure 2 Long-term and rehabilitation framework for the LTMV patient. Abbreviation LTMV, long-term mechanical ventilation.

Many policies and practices have been adopted by European countries for the management of contaminated sites. Information about the various national polices, the technical approaches for risk assessment, and the progress of rehabilitation activities in Europe has been compiled in the framework of two European networks—CARACS (Concerted Action for Risk Assessment for Contaminated Sites) and CLARINET (Contaminated Land Rehabilitation Network for Environmental Technologies)—which were funded by the European Commission. A detailed description of European national policies can be found in relevant publications2 3 and in the CLARINET website (http //www.clarinet.at). 

The recent approval and implementation of the European Water Framework Directive further emphasizes the role of biota as a tool for assessing aquatic environmental quality, in that it strives not only for the improvement of the chemical quality status of water bodies but also for the rehabilitation of their ecological status. In the light of these recommendations, it becomes essential to use biota to assess not only the chemical status of water bodies through contaminant load analysis, but also their ecological status, in what must be an integrated, multidisciplinary approach. 

International harmonization of soil quality standards (SQSs) has been discussed in the CARACAS (Concerted Action on Risk Assessment for Contaminated Sites in the European Union, 1995 to 1998) and CLARINET (Contaminated Land Rehabilitation Network for Environmental Technologies, 1998 to 2001) concerted actions (Vegter et al. 2003), and a form of the Soil Framework Directive is still under review by member states in the European Union, so the present guidance is both timely and relevant. 

Measurements, and concepts with which they are associated, can contribute to a shift from experience-based knowledge acquisition to rule-based, engineering-like methods. This requires (1) a widely accepted conceptual framework (i.e., known to assistive device manufacturers, rehabilitation engineers, and other professionals within the rehabilitation community), (2) a more complete set of measurement tools that are at least standardized with regard to the definition of the quantity measured, (3) special analysis and assessment software (that removes the resistance to the application of more rigorous methods by enhancing the quality of decisions as well as the speed with which they can be reached), and (4) properly trained practitioners. Each is a necessary but not sufficient component. Thus balanced progress is required in each of these areas. 

Of particular interest is the development of a rehabilitation glove (Figure 11.23). The glove [149] is to be used to provide continuous passive motion during rehabilitation via physiotherapy after major injury and surgery to the hand. Applications such as these provide an excellent framework for development of the performance criteria of artificial muscle fibers. Fibers with length of the order of 30 cm with 5% strain capabilities under significant (5 MPa) load are required. The advent of helical wire interconnects. 

In the United Kingdom, there are few specialized facilities for LTMV, as a result, patients may need to be managed for protracted periods within the ICU. The core team usually consists of the intensivist, nurse, and PT, with dieticians, pharmacists, and microbiologists making up the peripheral ICU team on a part-time basis (Fig. 3). The rehabilitation process should exist within a practical framework, coordinated by enthusiastic, knowledgeable, experienced, and motivated professionals. 

This classification is a useful distinction that can be applied to the conceptual rehabilitation model and framework (Figs. 4 and 5). The core ICU team undertakes the acute and intermediate phase of nonspecialized rehabilitation. The long-term phase is specialized rehabilitation and again undertaken by the core ICU team but in collaboration with other relevant specialist practitioners, such as speech and language and occupational therapy, to optimize the patients rehabilitation potential. 

This framework embraces the concept of whole-body rehabilitation, as described by Martin et al. (17), including physical and psychological aspects of care during the ICU stay. An essential component is the appointment of a coordinator, particularly in the intermediate and long-term phases, to ensure continuity and consistency. In the United Kingdom, the PT and nurse in the ICU are in a prime position to take on such a role. 

Mason, S.G., and G.E. Birch. In press. A general framework for brain-computer interface design. IEEE Transactions on Neural Systems and Rehabilitation Technology. 

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