Title: REFLECT - Recovery Following Intensive Care Treatment
Funder: Department of Health and Social Care

Abstract: Background: In 2012-13, 9,270 (8.6%) of the 108,261 patients discharged from Intensive Care Units (ICUs) in England and Wales died without leaving hospital (1). This mortality rate is higher than hospitalised groups considered to be at high risk (2&ndash;4) and is over five times the annual UK road accident death rate (5). Most of these patients were discharged from ICU with an expectation of survival (6 and ICNARC data). Local audit confirms that around 75% of patients who died in hospital after ICU discharge had aspects of their care which, if improved, may have increased survival. A sequence of national reports (9&ndash;14) suggest that changes in care in ward environments could lead to outcome improvements in critically ill patients. Aim: To develop a multi-faceted intervention to reduce in-hospital mortality rates in patients discharged from intensive care. Objectives To identify aspects of care to improve To prioritise aspects of care to be improved To inform the development of the intervention To finalise the intervention. Setting: Three hospitals representing three ICU types: district general, elective surgical, general medico-surgical. Investigation plan: STAGE ONE: Defining areas for improvement Areas will be identified using: interviews focus groups case reviews Interviews will be conducted with patients, relatives and staff to allow emerging themes to be explored across groups. Interviews will use a topic guide, based on completed work and input from patient representatives. We estimate data saturation will occur after ~20 interviews with patients and relatives and 20-30 staff interviews. Focus group topic guides will be developed from interview themes and completed work to encourage reflection on interview findings and allow new issues to arise. 3-4 focus groups will be required. Interviews and focus groups will be transcribed. A modified grounded theory approach will be used to identify emerging themes (65,66). Preliminary coding will be refined using the method of constant comparison (65) to produce a report for each theme. These reports will be analysed with a second researcher (67). Any differences in interpretation or emphasis will be resolved. Retrospective Case Record Review We will use established methods to review the case records of patients interviewed in this project (58,62). We will triangulate issues identified by patients and relatives with those found in the case records. We will compare the problems in care identified with those identified for non-survivors in previous work. STAGE 2 &ndash; Modelling the intervention Guided by a human factors researcher, a stakeholder group will prioritise areas for intervention from those identified in the interviews, focus groups and our earlier research. We will then undertake literature searches to check if these prioritised areas have been previously investigated in other hospitalised patient populations. To capture relevant successful methods for change implementation we will review: implementation methods used in the post-ICU hospitalised patient group implementation methods used in studies of our prioritised areas in other hospitalised patient populations Components of the multi-faceted intervention will be examined in a paper modelling exercise (68) to allow exploration of: interdependencies of components different implementation strategies challenges that may be encountered A stakeholder meeting will finalise the intervention. Our programme of work will develop and test a way of improving outcomes for hospitalised patients following intensive care. This project will identify which areas of care can be changed and determine how changes can be introduced. We will publish the outcomes of our qualitative work (interviews and focus groups) and our case review in relevant journals.

Lay abstract: Most patients discharged from an intensive care unit (ICU) are expected to go home. However, about 1 in 12 die unexpectedly on general wards before leaving hospital. The high death rate occurs despite hospitals using early warning scoring systems and visits from ICU teams. A plan which reduces this death rate is urgently needed. We will use several approaches to make sure that we get a clear picture of how to improve care. We will: Talk to patients, relatives, and staff with experience of ward care after ICU Look at the notes of patients cared for in wards after discharge from ICU. Look at published research to find known ways of improving care in this patient group. Patient representatives will help us use this information to design a plan to deliver better care to patients who have been in ICU, whilst they remain in hospital. Experts in introducing change will help design the best intervention. This project will combine information from several sources with experts skilled at making plans work. This will allow us to make the best possible plan. After this project, we want to test whether our plan could be put in place in our local hospitals to see if we could undertake a large trial. Over 2300 lives would be saved in the UK each year if our plan worked and stopped only a quarter of the unexpected deaths in patients discharged from ICU.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE