Passport to Successful Outcomes for Patients Admitted to

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Foreword

In the ever-evolving landscape of intensive care medicine, where each single

patient’s journey through critical illness is as unique as the individual themselves,
the significance of comprehensive, multidisciplinary care cannot be overstated. As
we navigate the complexities of ICU environments, it becomes increasingly appar-
ent that successful patient outcomes hinge not only on technological advancements
but, more crucially, on the collaborative efforts of dedicated healthcare profession-
als. This human chain is absolutely remarkable.
The second edition of “Passport to Successful ICU Discharge” stands as a testa-
ment to this collective commitment to excellence. Under the skilled editorship of
Carole Boulanger and David McWilliams, whose unbeatable dedication to research
and patient care has set a standard for excellence, this volume delves deeper into the
intricacies of ICU management, offering invaluable insights and evidence-based
practices for optimising patient recovery.
In the wake of the unprecedented challenges posed by the COVID-19 pandemic,
the importance of effective critical care has been thrust into the spotlight. In his
foreword to the first edition, Maurizio Cecconi’s poignant reflection on the essence
of ICU practice resonates profoundly, reminding us that beyond the ventilators and
monitors lies the beating heart of intensive care—the compassionate collaboration
of nurses, allied healthcare professionals, and clinicians.
“Passport to Successful Outcomes for Patients Admitted to ICU” transcends the
traditional confines of medical literature, offering a holistic framework for guiding
patients through every stage of their ICU journey. From the meticulous attention to
detail during admission to the comprehensive rehabilitation strategies aimed at pro-
moting independence and quality of life, each chapter encapsulates the essence of
patient-centred care. The multidisciplinary approach embraced within these pages
reflects a fundamental shift in our understanding of critical illness—a recognition
that true healing extends beyond the physical realm to encompass the emotional,
psychological, and social dimensions of recovery. As we strive to create environ-
ments conducive to healing, the significance of effective communication, infection
prevention, and psychological support emerges as indispensable pillars of care.
In essence, “Passport to Successful Outcomes for Patients Admitted to ICU”
serves as both a beacon of guidance and a testament to the unrestricted dedication
of ICU professionals worldwide. Its pages resonate with the collective wisdom of

v
vi Foreword

clinicians, researchers, and caregivers, united in their pursuit of excellence and

never-ending commitment to patient well-being.
As we embark on this journey through the corridors of critical care, may this
volume serve as a guiding light, illuminating the path towards successful patient
outcomes and reaffirming our shared commitment to compassionate, evidence-­
based practice.

President European Society of Intensive Care Medicine Elie Azoulay

Chef de Service de Médecine, Intensive & Reanimation
Hopital St Louis,
Paris, France
Preface

In 1892, Dr. William Osler in wrote,

it is much more important to know what sort of a patient has a disease than what sort of a
disease a patient has.

This sentiment still very much holds true today. The past few decades has seen
increasing numbers of patients admitted to critical care units, with high acuity of
illness and an increasingly complex array of comorbidities. Thankfully technologi-
cal advancements and developments in care delivery mean survival rates have
improved. However, with limited resources and stretched healthcare systems, there
is a risk that critical care becomes focused on the completion of tasks, losing sight
of the individuality of the person receiving that care.
A passport is well recognized as one of the earliest known documents certifying
the identity and key details of the bearer, primarily for the purposes of safe passage
of travel and return home at the end of a journey. Whilst no patient or their family
would choose an intensive care journey, the principles of safe passage do hold true
in this context and the goal is always a safe return home. The concept of a “pass-
port” for a critically ill patient therefore comprises the key aspects of care and man-
agement to enable safe passage. Avoidance of complications and the early
establishment of a relationship between the patient, their family, and the multi-­
professional team can have a significant impact on how the ICU journey progresses.
Person-centred care is at the heart of the intensive care journey and is valued among
the intensive care community—how far it reaches into busy intensive care units is
less easy to quantify.
Passport to Successful Outcomes for Patients Admitted to ICU-Meeting Goals of
Care has been created to highlight key aspects of intensive care from admission
through to discharge. Written by an expert multi-professional team of nurses and
key therapists from across the world, the ICU patient journey is presented through
the lens of individual experts making up the critical care team. The intention is to
signpost how focusing the spotlight on the patient as a whole can contribute to a
successful return of patients to their previous lives and families or facilitate a peace-
ful and dignified death. The authors present the latest evidence, emphasising the
attention to detail necessary to avoid ICU-related complications, coupled with
ensuring that care is person-centred. This edition builds on our first text Passport to

vii
viii Preface

Successful Discharge and provides a timely update reflecting the challenges and
innovations of the last couple of years. In addition, it is also acknowledged that for
some patients admitted to critical care survival is not always possible. A new chap-
ter has now been included to consider how holistic, multidisciplinary care is for the
person at the end of their life.
This is by no means an exhaustive text, but one which views the patient journey
from the point of admission with the goal of ensuring a successful outcome for
people admitted to critical care, whether that is returning the patient and family to
their previous lives or supporting them and their family to ensure a good death. It is
intended to be practical, informative, and thought provoking to ensure we maximise
the expertise of the multi-professional team in the patients’ interests.

Exeter, Devon, UK Carole Boulanger

Coventry, UK  David McWilliams
Contents

1 
The Person Before the Patient: The Importance of a Good History ������ 1
Fiona Howroyd and Andrew Lockwood
2 
Respiratory and Mechanical Ventilation Management:
Avoidance of Complications���������������������������������������������������������������������� 17
Roberto Martinez-Alejos, Ricardo Miguel Rodrigues-­Gomes,
and Joan-Daniel Martí
3 
Patient Care: From Body to Mind������������������������������������������������������������ 33
Silvia Calviño-Günther and Yann Vallod
4 
Nutrition: One Size Does Not Fit All�������������������������������������������������������� 49
Judith L. Merriweather
5 Promoting Independence�������������������������������������������������������������������������� 67
Camilla Dawson
6 Mobility and Function ������������������������������������������������������������������������������ 81
David McWilliams and Owen Gustafson
7 
Infection Prevention and Control: Simple Measures, Challenging
Implementation������������������������������������������������������������������������������������������ 97
Sonia O. Labeau, Stijn I. Blot, Silvia Calviño-Günther,
Elena Conoscenti, and Mireia Llauradó Serra
8 
The Power of Communication������������������������������������������������������������������ 115
Jackie McRae, Aeron Ginnelly, Helen Newman, Gemma Clunie,
and Mari Viviers
9 
The Intensive Care Unit Environment: Impact and Prevention������������ 133
Lotta Johansson and Deborah Dawson
10 
Psychology: Person-Centred Care a Key to Successful Recovery �������� 149
Julie Highfield, Matthew Beadman, and Dorothy Wade
11 Post-intensive Care Syndrome������������������������������������������������������������������ 171
Ramona O. Hopkins and David McWilliams
12 
End-of-Life Care: A Dignified Death ������������������������������������������������������ 181
Julie Benbenishty

ix
The Person Before the Patient:
The Importance of a Good History 1
Fiona Howroyd and Andrew Lockwood

1.1 Introduction

The Intensive Care Unit (ICU) is a complex and dynamic environment intended for
the care of the critically ill patient [1]. Receiving 24-h care, patients in the ICU are
carefully managed for life-threatening illness, through intricate multiorgan support
and continuous monitoring [2]. In the initial stages of recovery, treatment goals may
be short term, medically focused and interchangeable dependent on the patient’s
response. Anticipating a patient’s post-acute care needs for discharge may be diffi-
cult in the ICU due to the uncertainty of recovery and the rapid changing priorities
in a patient’s condition [3]. However, as medical care advances, the optimisation of
recovery as a therapeutic objective has developed increasing prominence rather than
mere survival alone [4]. For many survivors of critical illness, their discharge from
ICU is the start of an uncertain journey, facing numerous physical and non-physical
problems [5]. The overall sequelae of critical illness lead to reduced quality of life
amongst ICU survivors [6].
It is essential that the ICU team assesses and manages the physical and non-­
physical issues experienced by ICU patients as soon as possible, to optimise long-­
term outcomes. National guidelines in the UK serve as a useful template,
recommending the completion of an early and comprehensive assessment of physi-
cal and non-physical factors which may influence recovery and long-term outcomes
[4]. This assessment requires a detailed understanding of the patient’s history,
including their pre-admission functional and health status, helping to identify risk

F. Howroyd (*)
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
e-mail: [email protected]
A. Lockwood
Royal Devon University Healthcare NHS Foundation Trust, Exeter, Devon, UK
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2024
C. Boulanger, D. McWilliams (eds.), Passport to Successful Outcomes for
Patients Admitted to ICU, https://doi.org/10.1007/978-3-031-53019-7_1
2 F. Howroyd and A. Lockwood

factors for physical and non-physical morbidity [4]. Early assessment of such poten-
tial deficits is required to inform holistic care, facilitate early rehabilitation and
identify the ongoing specialist needs of survivors of critical illness, beyond their
ICU discharge [4]. This chapter will therefore explore the following:

• When to attain a patient history in the ICU.

• How to attain a patient history in the ICU.
• What a good history should include in the ICU.
• Why an early, detailed history is important.

Throughout the chapter, the practicalities and challenges of taking a good history
in the ICU will be considered, along with practical advice on how to overcome these
challenges. The benefits of a good history will also be discussed throughout the
chapter, considering how this can inform patient-centred care.

1.2 When to Attain a Patient History in the ICU

Although considered an essential component of patient-centred care, gaining a good

history in the ICU can be a challenging concept for healthcare professionals [7].
Every situation is unique, yet it is important for clinicians to gauge the right time to
approach patients and their relatives in a sensitive manner [8]. With the constant
noise, lights and alarms of machines, the ICU environment alone is considered to be
a hostile and stress-inducing place for both patients and their relatives [2].
Furthermore, there is the emotion and grief experienced as patients deal with the
uncertainty of critical and life-threatening illness [9]. Gaining a detailed history
about the patient in order to inform holistic rehabilitation goals may be misinter-
preted at the acute stages; either giving false hope of recovery or being deemed
insensitive when prognosis is uncertain [10]. A compassionate judgement is key;
considering that ICU patients and their family members experience high levels of
anxiety and psychological distress during the ICU admission [11, 12].
However, delays need to be avoided whilst selecting the optimal time to obtain
this detailed information. As recommended by the NICE guidelines, rehabilitation
needs to commence early in the ICU in order to prevent the physical and non-­
physical complications of critical illness. Specifically, the associated Quality
Standards advise that rehabilitation goals should be set and agreed by day 4 of ICU
admission [13]. At this time, patients may still be acutely unwell requiring multior-
gan support. Although this may seem early, it is important to recognise patients who
are critically ill for more than 4 days are at greater risk of physical and non-physical
symptoms. A delay in goal setting may subsequently delay the care and rehabilita-
tion required to overcome such negative effects. Early goal setting is therefore
essential, even if preventative in nature, ensuring a well-structured holistic rehabili-
tation plan that is documented, communicated and executed [14].
On balance, although this would seem to be at a stressful and uncertain time for
patients and their families, comprehensive assessment and detailed history taking
1 The Person Before the Patient: The Importance of a Good History 3

are required in the first few days of admission, in order to inform individualised
rehabilitation goals by day 4 [13]. Information gathering at such an early stage
therefore requires a systematic, professional and sensitive manner [8].

1.3 How to Obtain an Effective Patient History in the ICU

As well as gauging when it is an appropriate and sensitive time to gain a good

patient history, it is also important to consider the practicalities of how.

1.3.1 Taking a History from the Patient

The first line of approach to history taking should be from the patient themselves.
This will allow the clinician to hear the patients thoughts, beliefs and priorities in
their own words. Although challenging to approach in the ICU, when handled cor-
rectly, the interview process can concurrently support clinicians in developing a
therapeutic relationship. Through open communication, empathy and listening
skills, the clinical team is able to evoke a relationship of trust and understanding.
This may be reassuring for both patients and their relatives, whilst also helping to
initiate conversations regarding goals, expectations and discharge planning.
However, for the ICU patient, their ability to verbally communicate may often be
compromised due to the presence of artificial airway devices and respiratory system
support [15]. Furthermore, non-verbal communication methods such as gestures or
lip-reading are often ineffective and unsuccessful in the ICU due to factors such as
weakness or injury [16]. Attempting to communicate via non-verbal methods with
ICU patients can subsequently cause frustration, stress and anxiety, for patients,
relatives and staff [16].
As well as challenges with communication, history taking from the ICU patient
may also be limited by other common factors such as sedation or cognitive impair-
ment [17]. Delirium in the ICU is common and may also be associated with memory
impairments, reduced concentration, inattention and poor sleep [18]. Obtaining a
detailed and accurate history from the patient in the acute stages of critical illness
may therefore be challenging or even impossible, therefore other means may need
to be considered.

1.3.2 Taking a History from the Patient’s Relatives

Due to the implications of critical illness and ICU therapies, clinicians are often
required to collate information from patient relatives. Ideally the clinical team are
able to speak with the patients family on a face-to-face consultation, such as during
patient visiting hours. This allows the clinician to gauge a sensitive and appropriate
time to collate the patient history as part of a natural conversation. Family-centred
4 F. Howroyd and A. Lockwood

care and family visitation is advocated by ICU guidelines, with known benefits
upon patient outcomes [19–21].
However, coordination of timings between clinicians and visiting times may not
always be possible, therefore reliant instead upon telephone communication.
Although convenient, it is important to recognise that relatives can experience stress
and panic when receiving telephone calls from the hospital when a loved-one is in
ICU [22]. It is important to start the telephone call with reassurance and maintain
calm and empathetic communication throughout.
There has been significant learning and reflection following the COVID-19 pan-
demic regarding relative communication. In the height of the pandemic, hospital
visiting restrictions were implemented to maintain public safety [23–25]. In addi-
tion to the visitation restrictions, telephone communication was also challenging
due to face masks and personal protective equipment hampering the ability to hear
and speak clearly [23, 26]. This breakdown in family-centred ICU care had pro-
found effects, with moral distress, emotional exhaustion and reduced job satisafac-
tion reported amongst healthcare workers during the COVID-19 pandemic [21, 23,
25, 27].

1.3.3 Video Consultations

To lessen the effect of the COVID-19 quarantine restrictions, guidelines were pub-
lished to support alternative modes of communications and enable creative and flex-
ible family-centred ICU care [23, 28]. Although unable to replace the value of
physical presence at the bedside, video calls offered one alternative [22, 29]. ‘Virtual
visiting’ enabled family members in any geographical locations to connect with the
patient. It also allowed the patient to be immersed back into their everyday life and
virtually take them to their own home, or to wider members of their support net-
work, including pets [30]. Although there are conflicting perspectives regarding vir-
tual interactions, with care to be taken to adhere to patient consent and privacy, it
can continue to offer an alternative method of family communication when in-­
person visitation is limited [31].

1.3.4 Family Liaison Teams

Another useful communication tool adopted at the height of the COVID-19 pan-
demic was the use of Family Liaison Teams (FLT). FLT were specialist teams dedi-
cated to relative communication, information and support and were associated with
high levels of satisfaction by patient families [24, 32]. In some cases, they also
facilitated the ‘virtual visiting’, bedside photographs, voice recordings or music
playlists sent in by relatives [26].
Although visitation is now possible again, the COVID-19 pandemic has rein-
forced the importance of family members being informed and connected in ICU
patient care [29]. Whether in person, by telephone or a virtual platform, attaining a
1 The Person Before the Patient: The Importance of a Good History 5

patient history requires a sensitive approach due to the grief, stress and emotion
experienced by relatives of ICU patients [9].
It is important that appropriate time is given for retrieving a good history. It may
require time and perseverance to gain a detailed understanding of the patient, and
clinicians should consider that it is not always possible to gather all information in
a single meeting or from one individual. In order to help initiate and structure these
conversations, there are tools which may be used to help.

1.3.5 The Clinical Frailty Scale

Frailty, distinct from co-morbidity and age, is a state of vulnerability predisposing certain
individuals to increased risk of falls, delirium, disability, and mortality during hospitaliza-
tion, which consequently increases length of hospitalization stay [33].

Baseline functional status in addition to the burden of pre-existing illness is consid-

ered to have prognostic value in the ICU [34]. The development of critical illness
may lead to frailty in vulnerable patients; furthermore, critical illness may impede
recovery in those already considered frail [35]. Frailty is therefore an important
short-term prognostic tool, with frail patients more likely to experience adverse
events and have longer lengths of stay in ICU and hospital [36]. Furthermore, in the
longer term, frail patients are more likely to leave hospital with impaired functional
dependence and quality of life and have greater mortality [36].
The Clinical Frailty Scale (CFS) provides clinicians with an easily applicable
tool to stratify according to the level of vulnerability [33]. Although the components
of frailty are well known to be complex and diverse, time constraints necessitate a
simple assessment tool that is easy to complete on ICU admission, by patients or
their relatives [34] (Fig. 1.1). Although the CFS does not provide a detailed history,
in the early and acute stages, this may help ICU clinicians to understand the depen-
dency, or independency of their patients, considering health status, physical activity
levels and functional participation in activities of daily life. The CFS therefore helps
to develop a picture of physical and non-physical risk factors of ICU recovery and
may help clinicians to identify their patient’s potential rehabilitation and care needs.

1.3.6 Patient Questionnaires: Key Relative Involvement

Documents such as the ‘All About Me’ or ‘This is Me’ are commonly used in
dementia care and have been adapted for use in the ICU, where patients may not be
able to communicate key facts about themselves. These are useful tools when col-
lecting a patient history in the ICU (Fig. 1.2). The questionnaires aim to capture
detailed personal information about the patient, including their family and signifi-
cant others, hobbies, work and independence with activities of daily living. This
information is then recorded in a single document accessible for all staff involved in
the patient’s care. The use of this document, displayed with a photograph, serves as
6 F. Howroyd and A. Lockwood

Fig. 1.1 Clinical frailty scale. (Reproduced with permission from Dalhousie University)

a reminder of the person who is the patient. The frequent use of prone positioning
during the COVID-19 pandemic led to feelings of dehumanised, depersonalised and
‘faceless’ patient care [25]. A patient photograph can be a valuable way of allowing
staff to connect with their patients and knowing the ‘person’ before they became a
patient.
By providing a questionnaire to the family member, it allows them to write down
this information in their own time. Considering their stress, emotion and grief, this
can often be a more appropriate and sensitive way to collect a good history and can
subsequently be a more comfortable approach for healthcare professionals. Relatives
commonly report that completing the questionnaire is a therapeutic task, particu-
larly at a time when they feel helpless, valuing the importance of their input in
describing the person who has become our patient. It also prevents repetitive con-
versations for relatives who may come across many different professionals during
the course of the patient’s ICU admission.
From a clinician’s perspective, it is very useful to understand the patient’s history
from the relatives’ perspective, not only knowing their medical and social history
but also their likes, dislikes and aspects of their personality. This can help to person-
alise care and ensure that rehabilitation is patient centred. This can be comforting
and reassuring not only for the patient but also their relatives, knowing that their
nurse or therapist has taken the time to understand the patient and utilise the ‘All
About Me’ or ‘This is Me’ to inform person-centred care.
1 The Person Before the Patient: The Importance of a Good History 7

Fig. 1.2 Example of a ‘This is Me’ document

8 F. Howroyd and A. Lockwood

1.4 What a Good History Should Include in the ICU

The overall aim of the history is to inform patient-centred care that is respective of
and responsive to the individual patient’s preferences, needs and values. A good
history should therefore consider a holistic overview of the patient’s physical, psy-
chological and social needs, as listed in Table 1.1.

Table 1.1 Suggested topics and questions included in a detailed patient history
Topic Questions to consider
Family • Who does the patient live with?
• Who is their next of kin?
• Who is important to the patient? This may include direct family, close
friends, neighbours or pets
• Do family live locally? If not, will relatives be able to visit?
• When are family usually able visit the patient?
Mobility • Prior to admission could the patient mobilise independently?
• Did they require any mobility aids?
• Could they manage the stairs?
• Were they able to leave the house?
• What was their outdoor mobility like?
• What was their exercise tolerance like? If limited, why?
• Is there any history of falls?
Functional • Can the patient complete all activities of daily living independently?
independence Including washing, dressing, cooking, shopping, cleaning and house-work
and housing • Did the patient have any support with any functional activities?
• If so, who from?
• Did the patient require a package of care or assistance from any carers;
do they require social services support?
• Are they normally continent?
• Where does the patient live? Are they local?
• What type of accommodation do they live in?
• Are there stairs or steps to access the property?
• Is the bedroom and bathroom up or downstairs?
Hobbies, interests • Did the patient work prior to admission?
and employment • If not, when did they stop working and why?
• What do/did they do for a living?
• What do they like to do in their spare time?
• Do they have any hobbies?
• Do they follow any sports or teams?
• What TV and radio stations do they like?
• Do they like to listen to certain music?
Medical issues • Did the patient have any health problems prior to admission?
• How do their health problems affect them? Physically and non-­
physically including fatigue, mood or pain
• How are their health problems managed?
• Are they under any specialist medical or support teams?
• Have they required ICU or hospital care before?
• Were they deconditioned or malnourished pre-admission?
• Do they have any mental health issues?
• Any history of alcohol, drugs or smoking?
• Vaccination status?
• Any issues with their vision? Do they wear glasses?
• Any issues with their hearing? Do they wear hearing aids?
(continued)
1 The Person Before the Patient: The Importance of a Good History 9

Table 1.1 (continued)

Topic Questions to consider
Lifestyle • What is the patient’s normal, daily routine?
• Do they normally have any issues with sleep?
• Do they normally have any issues with pain?
• How do they like their appearance? E.g., are they clean shaven?
• What is their favourite food or drink?
Understanding • What is the patient’s perception of their own problems?
and expectations • What are their main concerns?
• Do they understand why these problems have occurred?
• What is their expectation of recovery?
• What is there understanding of what has happened?
• Do they have memory loss?
• Do they have insight and understanding?

It is important to ensure that history taking is a caring, empathetic conversation,

rather than a checklist, paying due attention to the primary language of the patient
and their relatives. History taking requires good communication and active listening
skills. The information is personal and important to the patient and their families, as
it is these finer details which make the patient a person. It is therefore important to
give the patient and their families time to convey this information, showing respect
and understanding during the stressful experience of ICU.

1.5 Why an Early, Detailed History Is Important

The rationale for why an early, detailed patient history is necessary and valuable to
patient care is detailed below, considering each of the topics outlined in Table 1.1.
To appreciate the importance of a history in the ICU, it may be beneficial to consider
patient examples.
Patient 1:
A 68-year-old patient has had three failed sedation holds and is now 6 days into
her ICU stay following emergency surgery. Staff have recorded that her waking
response is neurologically inappropriate and that she is agitated and confused. She
is listed for a tracheostomy today and potentially a head CT. A later detailed history
from the family reveals the patient normally wears glasses, has bilateral hearing
aids and her first language is Urdu. Her glasses and hearing aids were left at home,
and the sedation holds were completed without the family present, by English-­
speaking staff. She is normally very active and independent; she walks to the local
library every week and is a member of a book-club.
Patient 2:
An elderly patient is distressed and has pulled out her NG tube. She has remained
in bed for the last 5 days as she is restless and considered unsafe to get out of bed.
She has required low-dose sedation at night-time and therefore unable to transfer to
the ward. Following a detailed history, it is revealed that she has a background of
severe arthritis of the hip and requires daily analgesia. Despite her pain, she
remains fully independent, living at home alone. She is mobile with a walking-stick
and is able to drive, going to the shops and church on a weekly basis. Unfortunately,
10 F. Howroyd and A. Lockwood

her usual medication has not been prescribed. She was initially given morphine, yet
this was ceased as it caused constipation and nil further analgesia was prescribed.
She has not opened her bowels for 2 days.

1.5.1 Family: Key Relationships

Post-traumatic stress after ICU is common amongst patients and their relatives.
Involvement of family in the ICU can improve patient care as well as offer support
and reassurance to the family themselves [37]. Furthermore, rehabilitation goal set-
ting requires family support and engagement, as recommended by NICE guidelines
[4]. In the example of Patient 1, family members could offer support with language
interpretation as well as offer reassurance to the patient at a time of fear, disorienta-
tion and distress. Knowing who is important to the patient and including them in
care can be reassuring and comforting for the patient as well as their relatives. Once
Patient 1 had been successfully weaned from sedation, family could also help to
support with rehabilitation sessions by offering interpretation or provide incentive
to rehabilitation goals. For example, a short-term goal could be for the patient to
transfer to the chair for 1 hour periods during relative visiting hours or during a rela-
tive video call, to enable social interaction. Photographs and cards from family
members could be brought in to the patient’s bed-space to make the environment
feel less clinical and disorientating. Relatives often feel disempowered and sepa-
rated from their loved ones and simple involvement in aspects of care reinforces
their unique position in progression towards recovery, giving them a valued sense of
purpose. Another useful tool to help empower family members in their relatives care
is to encourage them to contribute to an ICU patient diary [38, 39]. The ICU diary
is a document that the ICU team and families can contribute to on a daily basis. The
diary can help patients understand what has happened to them during their admis-
sion and fills in the potential gaps in time.

1.5.2 Mobility

Having a good understanding of the patient’s baseline level of mobility is important to

help set expectations of recovery. This also helps to inform rehabilitation goals, which
should be communicated and implemented by all members of the ICU team. For
example, Patient 2 may require more intensive rehabilitation due to potential pain,
stiffness and weakness associated with arthritis in addition to bed rest and critical ill-
ness. In this instance, the nurses could help Patient 2 into the chair for her breakfast
and encourage her to participate in her own wash, then later the physiotherapy team
could review to practice mobilisation with a frame and complete a strengthening exer-
cise programme. Involving all members of the team helps to promote a normal daily
routine for the patient and also provides consistency to care and rehabilitation.
Understanding the patient’s history and baseline mobility at an early stage may also
help to inform the care and rehabilitation needs of the patient beyond ICU discharge.