Fixed wing \202 ights Continuous noise, vibration, changes in temperature, cramped space, ultraviolet radiation and time zone changes contribute to high levels of fatigue. Limited chance for rotation of medical personnel en route may mean extended working hours; therefor e, appropriate rest periods prior to and after \202 ights should be scheduled in staff ro sters. Staff should ensure they are physically \201 t to \202 y, not suffer- ing from t he effects of respiratory infections and be under the residual effects of neither medicatio n nor alcohol. Neither helicopters nor small \201 xed wing aircraft have toilet facilitie s. Axial tilt, acceleration and deceleration forces may be signi \201 cant during take-off , landing and extreme turbulence in \201 xed wing aircraft. Adverse effects on haemodynam ics and ICP may result. Altering patient orientation within the cabin during the \202 igh t to attenuate these forces is impractical. Equipment: key points Whilst the standard of monitoring needs to be equivalent to that in a n ICU, aeromedical equipment needs to ful \201 l additional criteria: \200 Portability and size. Each aircraft has a maximum permit- ted payload, and smaller helicopt ers are particularly limited in this regard. Trade-offs may have to be made with total fuel carried to allow additional weight, but this adversely affects \202 ight endurance. Airc raft performance is signi \201 cantly affected by ambient temperature and 581 CHAPTER 33.15 Aeromedical evacuation are essential. ABGs must be examined after the patient has been stabilized on the transport ation ventilator. For anything other than short transfers, monitoring ABGs en route is reco mmended. The importance of rigorously securing the airway cannot be overemphasized. All IV access, infusion lines, monitoring equipment, drains, etc. must be checked, rechecked and s ecured. Spare IV access is essential. Arrange infusion lines and monitoring equipment such that they are free from tangling and lie in such a fashion that they will be accessible acc ording to the particular aircraft used. Access to the patient \200\231s limbs, chest and ab domen may be restricted in \202 ight, depending on the layout of the aircraft. Always pla n for the worst case scenario, and consider how emer- gency re-intubation or CPR would be p erformed in the cabin. Prior to moving the patient, all loose equipment around the patient should be safely secured to guard against downdraft from helicopter blades or wind when mov ing the patient around exposed airport areas. The patient must be secured onto the stretche r with a harness approved for aviation use. Before leaving the referring hospital, a \201 nal check of the patient, equipment and team is performed and contact made with the aircre w to ensure the aircraft is fully fueled, ready to receive the patient and there are no pro blems with the planned routing. air \201 eld altitude. Less payload can be carried when taking off from hot, high air \201 elds. Suf \201 ciently rugged to withstand knocks and falls. Reliable and extended ba ttery life, with lightweight batteries preferably changeable without interrupting monitorin g. Do not rely on being able to connect equip- ment to aircraft electrical supply. Clear ba cklit displays that can be easily read even in direct sunlight and with vibration. Ability to withstand acceleration/deceleration forces, vibration, extreme temperature changes, and not inter- fere with aircraft avionics or electrical systems (e.g. de \201 - brillators). Ventilators should be oxygen ef \201 cient and deliver con- sistent tidal volumes irrespec tive of ambient pressure. Any integral on-board oxygen systems must be rigor- ously checked and maintained. Portable cylinders should be available in the event of systems failure, an d for patient transfer at each end of the \202 ight. Dedicated oxygen cylinders need to b e carried on commercial aircraft as the integral passenger supply is for use in emergency d ecompression only. Oxygen is dangerous air cargo and needs of \201 cial clearance for its carriage. Always plan suf \201 cient oxygen in case of patient respira- tory deterioration , aircraft delay or diversion. It is imperative that medical staff familiarize themselves w ith whichever oxygen system is used, and rigorously monitor consumption rate and contents. In-line oxygen analysers are recommended. Ideally the equipment can be neatly stacked to ma ximize access and minimize space occupied. Several organi- zations use specially designed e quipment bridges to facilitate this. Drugs and consumable equipment need to be easily vis- ualized and rapidly accessible. Thomas packs are popular as they are easily carried with ru cksack straps, and have compartmentalized sections with clear pockets. Equipment should be arranged according to indication for use, e.g. airway equipment. There must be a system for regular checks to ensure all equipment is present and serviceable, and a system to restock equipment rapidly after use. Drugs must be within expiry dates and kept at the required te mperature. Controlled drugs need writ- ten authority for carriage across borders. Transform ers and adaptors will be required to ensure charging capability overseas. \200 Safety The aircraft is an unfamiliar environment for most medical staff. Safety of the pati ent and aeromedical team is para- mount. Staff must undergo training in aeromedical evacua- tion and an orientation to the equipment and aircraft, with emphasis placed on common airc raft emergencies, emer- gency evacuation procedures, emergency depressurization, communicat ion procedures and survival equipment. The tail rotor and main rotors of helicopters can be lethal, and even provide hazardous obstacles when motionless. Underwater escape training f rom a helicopter simulator is recommended where \202 ights may take place over water. Wit hout proper training, disorientation and confusion are likely, and the ability for staff to provide the best patient care will be adversely affected. A study examining the ability of medical staff to provide CPR to mannequins dur- ing helicopter \202 ight showed signi \201 cant differences between those who had undergone training in aeromedical evacua- tion and those who had not. No pressure must be put on the aircrew to alter their normal safety procedures. The captain has the \201 nal say on whether the conditions are suitable for \202 ight, no matter what the condition of the patient. Clinical governance mechanisms sho uld be in place for reporting and investigation of critical incidents. Preparing the patient for transportation As far as possible the patient must be stabilized prior to transfer. Any necessary interventions and treatments need to be done prior to leav ing the referring hospital e.g. chest drains, -rays, invasive pressure monitoring. A formal handover of the patient by medical and nursing staff is essential, as are written notes, r esults of investiga- tions and copies of imaging procedures. The referring medical staff sh ould communicate directly with the receiv- ing institution medical staff. The transfer team should speak directly with the receiving staff if further advice is required, and con \201 rm an approximate arrival time. Recent blood results including biochemistry, glucose a nd hemoglobin Further reading Everest E, Munford B. Transportation of the critically ill. In: Bersten AD, Soni N, eds. Oh \200\231s intensive care manual, Philadelphia, PA: Butterworth-Heinemann, 2003: 21 \200\22332. Martin T. Aeromedical transportation. Aldershot, UK: Ashgate, 2006. 582 D GOLDHILL Outreach In 1990 the concept of the medical emergency team (MET) was introduced in Australia (see Ch apter 33.17). This began as an extension of the cardiac arrest team so that the MET respond ed not only to the need for CPR but to patients with gross physiological abnormality or oth er triggers including \200\230concern \200\231 on the part of the ward staff. In con- tras t, the initial philosophy behind the outreach concept was early recognition and interventio n with the aim of pre- venting problems. Over time, the differences between the systems hav e somewhat blurred as METs have also focused on education, early recognition and prevention . There are now many models and a variety of terms for outreach services. Some organization s have enthusiastically embraced the concept while others have reservations. METs are usual ly physician led, while critical care outreach services are typically nurse led but may inc lude other healthcare professionals, such as physiotherapists, as well as doctors. The term outreach was first used in the 1999 Audit Commission report \200\230Critical to S uccess \200\231. The UK Department of Health report \200\230Comprehensive Critical Care \200\231 (CCC) was published in 2000, and for the \201 rst time gave intensivists respons ibility for critically ill patients wherever they were in the hospital. Patients \200\231 c ritical care needs were de \201 ned by levels from 0 to 3, and critical care outreach serv ices were recommended as an integral part of each hospital \200\231s critical care services . CCC suggested that there were three main aims for outreach: to identify patients who are deteriorating to prevent admissions or ensure that the admission is timely; to enable disch arges; and to share critical care skills with ward staff and the community. Outreach is the refore involved in identifying Level 2 and 3 patients who are on wards and should be in a c ritical care area, and in supporting Level 1 patients on the wards Levels of care Level 0: patients whose needs can be met through normal ward care in an acut e hospital. Level 1: at risk of their condition deteriorating, or those recently relocated from higher levels of care and whose needs can be met on an acute ward with additional advi ce and support from the critical care team. Level 2: requiring more detailed observation or interven- tion including support for a single failing organ system or post-operative, care and those stepping down from higher levels of care. Level 3: requiring advanced respirator y support alone or basic respiratory support together with support of at least two organ sy stems. This level includes all complex patients requiring support for MOF. All the systems share the following features 1 A mechanism for identifying ward patients wh o are acutely ill, or have the potential to become so 2 A trigger system to initiate a response 3 A prompt response from personnel with the requi red competencies, experience and resources Recognizing critically ill patients Critically ill patients are identified from their histo ry, examination and investigations. Morbidity and mortality are associated with increasing age, co-morbidity and under- lying pathology. However, physiological abnormality is central to any system for recognizing critically ill patients. A high percentage of hospital inpat ients who arrest have abnormal physiological values in the hours preceding the arrest. The same has also been found in the hours before death on the hospital wards and also in patien ts admitted to ICU. In all systems abnormal physiological values are used to trigger a resp onse. These are incorporated into a variety of physiologically based early warning systems. The physi- ological variables are commonly blood pressure, heart rate, level of consciousn ess, respiratory rate, oxygen saturation and temperature. Other variables may be used, incl uding urine output and biochemical or other investiga- tions, events such as new seizures, or concern by the staff caring for the patient. Scoring systems are based upon combinations of physio- logical variables and various trigger thresholds. These may use gross abnormali ty in a single variable, aggregated weighted scoring with points awarded to increasing degr ees of abnormality, or combinations. METs tend to be based upon single parameter systems, w hereas the aggre- gate scoring systems are much more common in the UK. One advantage of an aggregate multiple parameter system is that it aids tracking critically ill patients by cha nges in score as well as the ability to trigger a graded response depending on the score. F or this reason, these scores may be called \200\230track and trigger \200\231 systems. How ever, aggregate scoring systems are more complex, and errors in data col- lection and calcu lating the score are more likely than with simpler scores. Another advantage of scoring sys tems in general is that they mandate a response where otherwise Background Outreach came about as a response to a realization that there are many patients on hospital wards who are critically ill or at risk of becoming so. Care for these patients is often suboptimal and is associated with increased mortality. Critical care beds are a s mall proportion of acute hospital beds and have high rates of occupancy. With the move towa rds fewer hospital beds and shorter stays, ward patients tend to be sicker, and care has to be responsive to deteriorations that may occur over a short period of time. Changes in med ical and nurse education have reduced training time in acute care, while key tasks such as measur- ing vital physiological signs are commonly delegated to untrained staff who may not understand the signi \201 cance of abnormal values. Previously, up to 30% of patients adm itted from the wards to the ICU required CPR before ICU admission, and the longer they were on the wards before ICU the higher their mortality. In addition, 25% of patients admitted to an ICU who die do so after they are discharged back to the wards following their \201 rst ICU admission. There is also evidence that premature discharges to the ward from ICU a re associated with an increased mortality. It is therefore clear that the care patients rec eive on the wards, both before and after their ICU admission, can be an important deter- mi nant of outcome. These patients are already in hospital and are therefore easily accessible . Outreach is one attempt to address this problem. 583 CHAPTER 33.16 Outreach how well routine hospital care addresses the problems of critically ill ward patients. this might be dependent upon an individual \200\231s decision. In addition, they have been shown to increase the frequency of recording of physiological parameters on general wards. There is no evidence to support one score over another, and the sensitivity and speci \201 city of the score depend cru- cially upon the trigger threshold. The future Outreach is one response to the perceived problem of critically ill patients on hospital wards. There may be other ways of addressing this problem including supporting the education and training of the primary team responsible, the intervention of acute physicia ns or expanding critical care beds to ensure that all who may bene \201 t are admitted at the earliest opportunity. In the UK, the funding for out- reach is uncertain, and is often taken from a stretched intensive care budget. NICE has published guidelines for the managem ent of acutely ill adults in hospital. These recommend many of the elements of the outreach system including the use of a physiologically based track and trigger system, trained staf f with competencies in monitoring, measurement and interpretation, and a graded response st rategy which is to be agreed and delivered locally. The response Nearly three-quarters of acute hospitals in England have a formal outreach ser vice. There is a wide variation in the proportion of hospital wards covered, the size and c ompo- sition of the team, and the balance between the provision of direct care and advice. Common interventions include changes in oxygen therapy, initiation of treatment limita- tio n, adjustment to pain management, nutrition, medication or vasoactive drugs, changes in pat ient position and the use of NIV. Most of the evidence for the bene \201 t of out- reach s ystems and METs has come from papers looking at outcomes before and after the introduction of these systems. This evidence suggests that outreach may decrease cardiac arrests, ICU re admission rates and hospital mortality. To date there have only been two good quality prosp ective studies of outreach and METs. In both of these studies education was an important in gredient in delivering the change in service. It is possible that this may be the most impo rtant element of any outreach service. The UK study performed in a single hospital found th at the outreach service reduced hospital mortality. The multi-center rand- omized MERIT stu dy in Australia found no difference in unexpected deaths, cardiac arrest rates or unplanned ICU admission between control and intervention groups. Further reading Department of Health. Comprehensive Critical Care. A review of adult critical care services. London: DoH, 2000. Gao H, McDonnell A, Harrison DA, et al. Systematic review and evaluation of physiological t rack and trigger warning systems for identifying at-risk patients on the ward. Intensive Ca re Medicine 2007; 33: 667 \200\22379. Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet 2000; 355: 1138 \200\22342. Goldhill DR, McNarry AF, Hadjianastassiou VG, et al. The longer patients are in hospital be fore Intensive Care admission the higher their mortality. Intensive Care Med 2004; 30: 1908 \200\22313. Goldhill DR, Sumner A. Outcome of intensive care patients in a group of British intensive c are units. Crit Care Med 1998; 26: 1337 \200\22345. A whole systems approach Evidence suggests that physiological measurements may be taken inf requently, even in patients who are critically ill. When values are abnormal and ful \201 l the requirements to trigger a response, the appropriate teams is not always called. When teams are called, if they are to make a differ- ence they must have the necessary competenc ies, experi- ence and resources. Finally all outreach systems are based upon the presumptio n that early recognition and interven- tion will improve outcome for some patients. It shou ld be recognized that death may be inevitable, but it should also be acknowledged that agre eing the limits to intervention or resuscitation is a legitimate and bene \201 cial outcom e that may involve the outreach service. There are, therefore, many elements which need to come together if outreach is to make a difference, and its effect depends crucially upon Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) syst em: a cluster-randomized controlled trial. Lancet 2005; 365: 2091 \200\2237. Intensive Care Society. Levels of critical care for adult patients. London: Intensive Care Society, 2002. Lee A, Bishop G, Hillman KM, et al. The Medical Emergency Team. Anaesthes Intensive Care 1995; 23: 183 \200\2236. McQuillan P, Pilkington S, Allan A, et al. Con \201 dential inquiry into quality of care b efore admission to intensive care. BMJ 1998; 316: 1853 \200\2238. Priestley G, Watson W, Rashidian A, et al. Introducing Critical Care Outreach: a ward-rando mized trail of phased introduction in a general hospital. Intensive Care Med 2004; 30: 1398 \200\223404. 584 K HILLMAN Medical emergency teams with the general awareness of an at-risk patient who requires urgent attention. A medical emergency team (MET) is a concept designed to identify and treat serious illness as early as possible. Sometimes called a rapid response team or, if the response is determi ned by different criteria, then the patient at-risk team (PART), or modi \201 ed early war ning score (MEWS) team. These teams can also be part of outreach initiatives which manage s eriously ill and at-risk patients outside the ICU. Table 33.17.1 MET criteria. Obstructed airway Respiratory rate: <4/min >26/min Heart rate <40/min >130/min SBP <90mm Hg Seizures A sudden decrease in the GCS of >2 Staff concern The seriously ill at-risk syndrome It helps to consider the seriously ill at-risk patient i n the same way as a patient with coronary artery syndrome. Irrespective of the cause of the illness, patients who have even minor degrees of hypoxia and/or ischaemia are at risk of p otentially serious complications. Hypoxia and ischae- mia can result in cytokine cascades a nd organ dysfunction, leading to MOF often requiring admission to the ICU. More than half o f all hospitalized patients who have serious adverse events such as cardiac arrests, unexpe cted deaths or unanticipated admissions to the ICU have marked abnormalities in vital signs or other observations such as coma or seizures for many hours preceding the event. Rather than wait until the patient develops MOD and requires admission to the ICU, even minor degr ees of hypoxia and ischaemia should be detected and corrected as early as possible. Reasons for the high incidence of serious and untreated events in hospitals world-wide include lac k of knowledge and experience in the doctors first called to see the patient, often due to the failure to recognize a seriously ill patient until they are at the point of a cardiac a rrest, a reluctance to call for help when advice is needed and a tendency for intensive car e specialists to wait until the patient becomes ill enough to require multi-organ support o r perhaps until their heart stops and they require CPR before seeing them. Acute hospitals are generally focused around a medical team or a geographical site, and so the seriously il l at-risk patient can easily fall through the usual safety nets within these vertical const raints. This situation is compounded by the changing nature of patients now admitted to acu te hospitals. They are generally older with multiple co-morbidities, having more invasive a nd complex proce- dures and therapies. They are more vulnerable to even minor degrees of ac ute deterioration and require earlier and more aggressive intervention in order to prevent serious organ dysfunction. De \201 ning the seriously ill patient is the \201 rst step in a system designed to mini mize complications and adverse outcomes. It is sometimes called the afferent arm. A major w eakness in de \201 ning the seriously ill at-risk patient is the frequency with which we m easure vital signs or observe patients in hospital general wards. Measuring the vital signs every 4h may be inadequate to detect acute and potentially dangerous early signs of deteri oration. Respiratory rate, one of the most important early detec- tors of serious illness, is often not measured at all or is estimated inaccurately. More continuous, non-invasive me asurement of vital signs in hospitalized patients on general wards should provide a safer e nvironment. The team It has been clearly demonstrated that the existing system of home teams caring for patients does not provide adequate care for seriously ill at-risk patients. It is tempting to suggest that training every doctor working in acute hospitals in aspects of acute resus citation would provide better care. There is no evidence, as yet, to support this and, even if there was, it would require signi \201 cant resources and expense in order to achieve an adequate response to the seriously ill at all times in an acute hospital. Rapid response teams and outreach programs are con- stituted in many different ways. Some use nursing sta ff to assess patients initially and call on doctors if appropriate. Many teams are simply h ospital cardiac arrest teams rebadged as a MET or MET-like team. It is important that each team has at least one person who is trained in all aspects of resuscitation and available a t all times. Members of the team should be formally trained in advanced resus- citation and how to work effectively in teams. Simulators are useful for this purpose. The response to the seriously ill patient is often referred to as the afferent arm. De \201 ning the seriousy ill criteria The MET criteria (Table 33.17.1) de \201 ne the so rt of patient who requires urgent attention. Most calling criteria rely on serious abnormal ities in simple vital signs such as pulse rate, respiratory rate and blood pressure, as wel l as observational abnormalities such as seizures, obstructed airway and a decrease in the level of consciousness. Staff concern is usually added to the criteria as it empowers, espe cially nursing staff to seek immediate assistance from trained and experienced doctors when needed. Some criteria use a tiered response, using the home team or specially trained nurs ing staff to assess the at-risk patient initially. Some also use other criteria such as uri ne output levels, temperature and SpO2. The exact levels of abnor- malities are less import ant than providing all hospital staff Implementation The implementation of a new system such as the MET involves different and di f \201 cult challenges. Staff across the whole hospital need to be aware of the criteria f or calling the team, and they must be and feel empowered to call the team at any time. Impl ementation is facilitated by auditing the effectiveness of the system by data collection. F or example, information could be collected on all patients 585 CHAPTER 33.17 Medical emergency teams serious ischaemia or hypoxia, treatment should not be delayed until they became ill enough to require ventilation and dialysis or have a cardiac arrest, and no intensive care physici ans would say otherwise. It is doubtful that the ethics committees would ever allow us to c onduct the de \201 nitive trial by randomizing patients into early or late treatment of th e seriously ill. who die, have a cardiac arrest or are admitted unexpectedly to the ICU. Patients who have a \200\230do-not-resuscitate \200\231 order need to be excluded. Those who had MET criteria in the 24h before the event and where a call had not been made then need to be highlighted as \200\230potentially preventable \200\231. These types of data are essential when imple menting a MET system as they de \201 ne whether the hospital has a problem and the extent of the problem. The data should be packaged in a simple and attractive way and distributed widely throughout the hospital, e.g. to all senior clinicians, all departments and patient areas, to the administration, as well as to hospital bodies and committees responsible for quality assurance. Weekly hospital-wide meetings presenting the number of calls, reasons fo r calling, and outcomes also help in the effective implementation of a hospital-wide system . Possible barriers to implementation need to be identi \201 ed before implementation. The se may include the cost of initially establishing the system, such as data analysers and co llators, staff to organize the meetings, and staff to follow-up implementation issues acros s the hospital. Other factors which may assist in the implementation of a MET system includ e gaining leadership support from within the hospital, with administrative and clinical lea der- ship concentrating on the bene \201 ts of early intervention. Establish a taskforce o r committee to set up the system, develop written policies and procedures, promote educa- t ion programs and coordinate a pilot system. In any organization, there will always be indiv iduals who will be threatened by change. The availability of data is the most powerful way around these problems. It is very dif \201 cult to argue against treating patients as earl y as possible rather than waiting until they die or have a cardiac arrest. ICU without walls As the specialty of intensive care has matured, the exper- tise of physic ians working with the seriously ill within the four walls of the ICU is increasingly being utilized to advise on the care of at-risk patients in other parts of the hospital both befo re and after admission to the ICU. Many intensive care staff are now electively consulted o n seriously ill patients long before they would require being admitted to the ICU. Intensiv e care nursing staff are often involved in outreach services, where they see at-risk patien ts, advise nursing colleagues on general wards and conduct educational programs. Within thi s system, certain at-risk patients such as those recently discharged from ICUs are all elec tively seen. Intensive care staff are also being increasingly involved in activities such a s acute trauma management and early management of sepsis, both in the emergency department and in general wards. This is in response to increasing evidence that early management of c ritical illness results in improved outcomes. Further reading Bright D, Walker W, Bion J. Clinical review: outreach \200\224a strategy fo r improving the care of the acutely ill hospitalized patient. Crit Care 2004; 8: 33 \200 \22340. Hillman K, Alexandrou E, Flabouris M, et al. Clinical outcome indicators in acute hospital medicine. Clin Intensive Care 2000; 11: 89 \200\22394. Evidence There is evidence in before and after and case-controlled studies that the MET sys tem reduces serious adverse events such as cardiac arrests, deaths and unexpected admission s to the ICU. Despite the fact that a larger cluster RCT was inconclusive and underpowered, many countries around the world now have a MET-type system in their hospital. It makes sen se, and there are many other activities in healthcare which have no level 1 evidence but wo uld be impossible to abandon, e.g. such as ICU or even hospital admission. Common sense dic tates that in a patient with Hillman K, Parr M, Flabouris A, et al. Rede \201 ning in-hospital resusci- tation: the con cept of the medical emergency team. Resuscitation 2001; 48: 105-10. Lee A, Bishop G, Hillman KM, et al. The medical emergency team. Anaesth Intensive Care 1995; 23: 183 \200\2236. MERIT Study Investigators. Introduction of the medical emergency team (MET) system: a clust er-randomized controlled trial. Lancet 2005; 365: 2091 \200\2237. 586 C JONES & RD GRIFFITHS Critical care follow-up Introduction Research into outcome following critical illness has focused mainly on mortali ty after discharge from the ICU, but the focus is shifting to morbidity, rehabilitation and aiding patients to rebuild their health. Many ICU patients report physical, psychological and cognitive problems, which may require assessment and appropriate care planning. Early r ecognition of problems through formal follow-up, both ward and out-patient clinic based, al lows the prompt refer- ral of these patients for appropriate, timely help before the condit ion becomes chronic. damage, or temporary due to sedative drugs, which may recover with time. One recent study s uggests that although some patients improve with time, a signi \201 cant number remain imp aired and may have problems with tasks such as \201 nancial management and driving. Interventions to aid physical and psychological recovery Rehabilitation programs While ther e is increasing evidence of physical and psycho- logical problems during recovery from crit ical illness, little work has been carried out on rehabilitation in this population, whilst rehabilitation programs in other patient groups, with both acute and chronic illness, have shown improvements in physical functioning and reduced psychological distress. To achieve successful rehabilitation of ICU patients, a multi-modal program containing physical, psych ological and cognitive elements would be needed. Patients do not necessarily follow a set c hronological pathway, so any pro- gramme has to be individual with regular assessment of ph ysical, psychological or cognitive problems. The provision of a multi-modal self-help recov ery package has been shown to accelerate the physical recovery of general ICU patients in a n RCT, blinded at follow-up. The program consisted of a 6-week rehabilitation manual that p rovided information on a wide range of topics, such as the possible physical, psychosocial and psychological problems after critical illness, and a comprehensive exercise program. A total of 126 patients were random- ized to receive either the ICU recovery manual program o r standard follow-up. At both the 2 and 6 month follow- up physical recovery was faster in the recovery manual patients than in the controls (P = 0.006). It also had an impact on smo king cessation, with signi \201 cantly more inter- vention patients not smoking in the 6 m onths post-ICU compared with the control group (relative risk reduction 89%, 95% CI 98 \200 \22336%). This has considerable importance as it improves the chance of lung recovery. Psyc hological recovery was more complex, with a non- signi \201 cant (P = 0.06) trend to a low er rate of depression at 2 months after ICU discharge (12 vs 25%). More impor- tantly, ther e were no differences in levels of anxiety and PTSD-related symptoms between the groups at 6 months. Further analysis showed that those patients recalling delusional memories from th eir time on ICU were signi \201 - cantly more anxious and had higher levels of PTSD-relate d symptoms than those who did not have these memories, regardless of whether or not they ha d received the reha- bilitation program. Clearly, such patients need to be identi \201 ed and referred for appropriate help. At present, in the UK, the provision of specialist ICU r eha- bilitation after hospital discharge is almost non-existent. A recent survey of physiot herapists at 36 large UK hospi- tals showed that there was some ward rehabilitation, but th at 93% of respondents felt there was a need for follow-up services to identify problems and to ensure that patients achieved their full recovery. Only a few hospitals were found to h ave a speci \201 c rehabilitation team for ICU patients. Long-term follow-up There would seem to be little point undertaking longer term follow-up o f ICU patients unless appropriate help can be offered where needed. For many patients, the simple provision of advice about the speed of recovery combined with a stepped care approac h to assessment and care plan- ning is suf \201 cient to meet their needs. Physical recove ry after discharge from the ICU is, on the whole, excellent. However, for some patients, pa rticularly those aged >50yrs and those staying longer in ICU, physical recovery from critic al illness is prolonged, in some cases taking >1yr. Loss of lean body mass, mainly skeletal muscle, occurs in the catabolic phase of illness, leading to profound muscle weakness; the diaphragm and other skeletal muscle of the respiratory system are not protected from this. Rebuilding of lost muscle occurs slowly and requires both physical activity and good nutri tion. In addition, some patients may develop critical illness polyneuropathy (CIP), which i s characterized by axonal degeneration of motor nerves. Longer stay patients often report d if \201 culty climbing the stairs even 2 months after ICU discharge. They may have dif \201 culty walking outdoors and often tend to continue using a wheel- chair. Poor muscle st rength and easy fatigability account for some of the dif \201 culty in getting up if they fall. This can lead to a feeling of vulnerability and fear of falling. Psychological issues during recovery The psychological sequelae of critical illness have on ly just begun to be recognized. There may be profound long- term psychological and psychoso cial effects. An early questionnaire study of 3655 patients found a high incidence of psych osocial dysfunction, particularly in younger individuals. High levels of anxiety, depressio n, and post- traumatic stress disorder (PTSD) have also been reported. Such problems can ha ve a signi \201 cant long-term detrimental impact on both the patients \200\231 and their family \200\231s quality of life. Many patients are amnesic for parts of their time in ICU, as well as regarding events prior to admission. A delusional memory of hallucinations, nig htmares or paranoid delu- sions recalled from the time in ICU may be the traumatic event th at precipitates the development of PTSD. Recall of delusional memories may be increased in patients who have a previous history of psychological problems before admission to ICU. Cognitive de \201 cits following critical illness It has been shown that signi \201 cant cognitive de \201 cits may remain after critical illness. At present, it is unclear whethe r these cognitive de \201 cits are permanent, due to neurological 587 CHAPTER 33.18 Critical care follow-up ICU diaries The patients \200\231 amnesia for the time in the ICU can hinder their recovery , as many patients do not understand how ill they have been and consequently the length of time it will take them to get back to normal. ICU diaries have become increasingly popular. These diaries are a day by day record of the patient \200\231s stay in ICU, written in eve ryday language by the ICU staff and the patient \200\231s family. It also includes photogra phs taken at points of change in the patient \200\231s illness. These diaries are popular w ith patients and seem to help them rebuild a memory of their illness. Where the patient has periods of agitation, confusion or seemed to be hallucinating, this is recorded in the dia ry and seems to help the patient to identify the point at which delusional memories may hav e occurred. An example of this is a patient whose memory for ICU was being in a \201 re a nd having to be rescued by \201 remen. This memory kept replay- ing as a \202 ashback a nd hindering her recovery. When she read her diary she discovered she had gone to theater u rgently and she decided that this was where her delu- sional memory had come from. Each tim e she had a \202 ash- back of this memory she read her diary to put it in context. An ICU diary is a simple therapy that has the potential to reduce the psychological impact of suc h memories, and is undergoing further research to examine its impact on PTSD symptoms. PTSS-14 (see www.i-canuk.org.uk for copies of ques- tionnaires). However, it is important t hat staff have some training in PTSD assessment and can recognize how the patient is coping . Some individuals will be able to cope with quite high levels of symptoms, and feel that t hey can manage on their own. These individuals can be reassessed after 1 month. The provis ion of counseling, psychotherapy or psychology services targeted at post-ICU patients is al most non- existent in the UK. The growth of counseling services for patients diagnosed with cancer has arisen from the recog- nition of the psychological impact of such a severe illn ess. Perhaps critical care providers need to think along similar lines because of the high risk of psychological effects for both patients and families following an illness in ICU. T he correlation between high levels of PTSD-related symptoms in patients and their families points to the need for family therapy. Conclusion The physical, psychological and cognitive sequelae of critical illness can be an enormous burden on both patients and their families. Care must continue long after dischar ge from the ICU, and a prolonged recovery time can be expected. The pathway of care offered to patients after such a severe illness needs to be improved to ensure that patients reach their full recovery potential. ICU physicians, nurses, physiotherapists and other professi onals have important roles to play in the management of patients after discharge.