Outline the important problems encountered by the patient  following hospital discharge after a prolonged period of stay in the Intensive Care Unit.

 List two (2) tools available to assess the functional  status of such a patient.

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College Answer

Many problems are encountered after hospital discharge. The important problems include Patients have usually had a tracheostomy (and/or prolonged endotracheal intubation) - complications associated with these include laryngeal pathology [eg. polyps, ulcers], aspiration, difficulty with swallowing etc.

°     Limitation of mobility for some time – muscle tone, joint stiffness, Chronic Inflammatory
Polyneuropathy 
°     Skin – hair loss, itching
°     Sexual dysfunction
°     Psychological problems – loss of memory, stress, nightmares, Post Traumatic Stress Disorder, depression, chronic fatigue syndrome
°     Infectious: colonisation with resistant organisms (eg. MRSA)
°     Miscellaneous (loss of taste, loss of appetite, ocular trauma, scarring near region of tape fixing for ETT)
°     Decreased visual acuity in patients who are profoundly hypotensive.
°     Unnecessary medication – Frequently medication commenced in ICU is commenced post discharge.

Tools to asses quality include:

Quality Adjusted Life Years (objective measure),

HAD – Hospital Anxiety & Depression,

SF 36,

PQOL (perceived quality of life),

EuroQOL – European tool
Simpler measures include Glasgow Outcome Scale.

Some hospitals utilise follow up clinics.

Discussion

This question is heavily based on Oh's Manual Chapter 8 (Common  problems  after  ICU).

A systematic response would resemble the following:

  • Tracheostomy:
    • Tracheal stenosis
    • Tethering of skin
  • Mobility:
    • Muscle wasting, neuromyopathy
    • Slow recovery of normal function (up to 1 year)
  • Skin
    • Hair loss
    • Nail ridging
    • MRSA colonisation
    • Facial scraring due to pressure areas from NGT and ETT
  • Sexual dysfunction
    • a 39% incidence
  • Psychological problems
    • PTSD, in about 15% (27.5% for ARDS survivors)

The question about tools to assess the quality of life is derived from Oh's Manual as well, specifically Box 8.1 on page 62 of the new edition ("Quality of life tool examples").

The contents of this box:

  • QALY(Quality Adjusted Life Years - the only objective tool)
  • HAD (Hospital Anxiety and Depression)
  • PQOL (Percieved Quality of Life)
  • EuroQol
  • SF 36 (36 item short-form survey)

References

References

Oh's Intensive Care manual: Chapter 8 (pp.61)  Common  problems  after  ICU   by Carl  S  Waldmann  and  Evelyn  Corner