Exploring the long-term consequences of musculoskeletal impairment following critical illness

Three quarters of patients admitted to an intensive care unit (ICU) are surviving to discharge from the acute hospital, despite an increasing population who are older, frailer and with significant multi-morbidities. More than half of critical care survivors experience at least one or more elements of post intensive care syndrome (PICS). The impact of these problems can be profound as patients struggle to function in daily life, with high rates of new unemployment and healthcare utilisation. The impact of PICS also extends to family members. The focus of this research will be on the post-hospital recovery for this patient population and their families. There are multiple specific healthcare problems contributing to poor physical function for patients with musculoskeletal (MSK) ill health being present in 59% of critical care survivors. To date, post-ICU rehabilitation interventions have failed to demonstrate sustained improvement in physical function. Understanding the perspectives of patients, family members, and healthcare professionals (HCP) can contribute to informing the delivery of effective rehabilitation services after critical illness. Qualitative investigations have concentrated on the transition of care beyond the ICU and engagement with acute rehabilitation focusing on recalibrating vulnerability to a sense of oneself. Reported experiences extend to unmet rehabilitation needs following hospital discharge, and a care burden placed upon family members as their loved ones struggle due to poor physical function. The aims of this thesis are to understand the experiences of patients living with MSK impairments following critical illness, and to inform future intervention development. Objectives The objectives of this thesis are: ● To synthesise primary qualitative studies reporting experiences of post-hospital recovery for critical care survivors, their family and the HCPs supporting them. ● To gain an in-depth understanding of the lived experiences of patients living with MSK impairment after critical illness and their families supporting them. ● To explore the lived experience of HCPs in supporting patients with MSK impairment following critical illness. ● To synthesise and integrate the case study findings exploring service provision and delivery of post hospital rehabilitation following critical illness. A meta-ethnography of 38 studies synthesised experiences into four themes: ‘I survived, but I didn’t thrive,’ ‘Healthcare was there to save my life, but not for my long-term recovery’, ‘I am a burden on my family, and they felt the weight of carrying me’ and ‘My body still doesn’t work like it used to’. This review provided an overarching interpretation of the experiences of patients, family members and HCPs recovering from critical illness. Physical impairments are diverse, commonly prevent patients thriving, and result in patients perceiving themselves as a burden on their families. To overcome the weight of this burden, families try to adapt to their new roles and responsibilities. Research gaps identified included the exploration of the unmet need for follow-up rehabilitation after critical illness and the experiences of the impact of specific healthcare problems contributing to physical impairment. The findings and future research directions of the meta-ethnography informed the development and design of the semi-structured interviews within the qualitative case investigation of patients living, and/or families and HCPs supporting those living, with MSK impairments following critical illness. A multicentre qualitative case study was undertaken across four NHS hospital sites in the United Kingdom. Six to nine months after discharge from ICU patients, family members and HCPs were invited to discuss their experiences in semi-structured interviews. A hermeneutic phenomenological approach was taken. All interviews were audio-recorded, transcribed verbatim and thematically analysed. 11 patient participants (36% female), four family members (75% female) and 13 HCP (69% female) across four professions were interviewed. There were five themes related to the lived experience of MSK problems: ‘I cradled my body due to the pain and weakness', ‘My daily life was fractured’, ‘The patients reported, so we referred on…’, ‘Their complexity is challenging, and they longed for structured rehab’ and ‘I just want to be back to normal for myself and my family’. These findings illuminated the experience of musculoskeletal ill health following critical illness as being problematic, contributing to patients' struggles to engage with daily activities, family time and return to work. HCP reported experiences of how they identified the need for intervention to address these complex MSK problems and often made onward referrals to facilitate this. However, patients and families discussed the challenges of accessing MSK interventions. From interviewed HCP, variations across cases in service delivery were identified. These included variations in interventions delivery and how modifications were employed inclusive of clinical, cultural and socioeconomic considerations. Cases were bound by hospital trust and locality. All sites completed a service lead questionnaire and provided a total of 19 documents for analysis. The findings were aligned to an ecological model of health. Cases demonstrated variations of hospital types, ICU types including number of beds, and HCP roles and responsibilities. There were differences across the cases in terms of clinic timing and focus; rehabilitation assessments, signposting or treatment delivery; National Health Service (NHS) and non-NHS collaborations. There were similarities across the cases in terms of service ethos, breadth of MDT and provision of educational resources. The interview and case study findings were integrated aligned to the International Classification of Functioning, Disability and Health model which contextualises a patient’s level of functioning through their biopsychosocial sphere. The integration enhances an understanding of the recovery following critical illness with pain and weakness being problematic, the challenges of delivering and engaging with MSK rehabilitation and social considerations such as motivators, cultural needs and service ethos. There are tensions between HCP referring onwards for and patients receiving rehabilitation interventions; between group and individual exercises; and between patient and family impressions of education and expectations of recovery compared to the volume of educational resources. The case study findings are synergistic with the known variations in ICU follow-up clinics and rehabilitation services as documented within the clinical guidance. In summary, MSK ill health following critical illness is problematic, contributing to patients' struggle to engage with daily activities, family time and return to work. HCP feel they recognise the need for intervention to address these complex problems and often make onward referrals to facilitate this. However, there is a mismatch between perspectives suggesting referrals do not translate into patients receiving interventions as they report a lack of access to MSK treatment as a major challenge. Future post-ICU rehabilitation services need to address the management of MSK problems for these patients and the effectiveness and experience of these should be explored.

Grantor dc:publisher

Oxford Brookes University

Author dc:creator

• King, Elizabeth

Contributors dc:contributor

• Williams, Mark
• Vollam, Sarah
• Williams, Annabel

Statement dc:rights

• All rights reserved

Language dc:language

en

DOI dc:identifier

https://doi.org/10.24384/2hcc-bg23

OAI identifier oai:identifier

tle:cca65de8-4ce7-4ee0-8dc5-ea94b34684bf:d6bd9758-527a-46cd-bfe2-c433766e8fca:1