What was the problem?
The Freeman Hospital's 22-bed integrated critical care unit was experiencing a demanding caseload combined with limited capacity.
This was preventing the unit from carrying out enhanced mobilisation for postoperative patients, in accordance with local enhanced recovery protocols.
The team was also unable to provide any follow-up care for long-stay patients after discharge from critical care, and there was no co-ordinated rehabilitation after critical illness (RaCI) pathway.
There was little scope to rehabilitate long-term patients at weekends, when the unit relied on one senior physiotherapist.
This meant patients requiring respiratory care were prioritised; elective patients undergoing surgery on Fridays or at the weekend had to wait until Monday to see a physiotherapist.
What was the solution?
A Band 4 physiotherapy associate practitioner role was introduced into the critical care unit. Their role included:
- managing an independent caseload of non-complex surgical patients from the day after their operation
- delivering enhanced early mobilisation, seven days a week
- carrying out basic respiratory assessment and provide treatment/advice
- helping provide individualised rehabilitation sessions and exercise programmes for long term patients
The trust created two posts (amounting to 1.8 whole-time equivalents), initially for a six-month pilot project.
This ensured seven-day cover with overlap two days a week, and freed time for a physiotherapist to provide a new RaCI service.
The practitioners undertook four weeks' supervised training in the unit before beginning their independent caseloads.
What were the results?
During the pilot:
- physiotherapy for surgical patients at weekends increased from an average of 43 minutes to 8 hours and 15 minutes
- capacity was sufficient to provide some rehabilitation sessions at weekends for patients with more complex requirements
- elective surgical patients left critical care mode independent than previously, with a 34.7% improvement in functional mobility outcome score
- length of stay on the unit for elective surgical patients decreased by 9.6%
- admissions to the unit increased by 11.3% - an indication of increased capacity
- the RaCI service increased compliance with NICE guidance; initially from zero to 90%, then subsequently to 95%
Following the pilot's success, the posts were made permanent. The project has won several awards.
What were the learning points?
- using competent and skilled non-qualified staff in an innovative role, the trust reorganised its resources to meet the complex needs of two groups of critical care patients — all for a relatively small financial investment
- gaining the multidisciplinary team's engagement was essential to the pilot's success
- a senior physiotherapist was best placed to develop, co-ordinate and lead the RaCI service due to their specialist knowledge and skills in rehabilitation and critical care