Enhanced Recovery After Critical Care (ERACC): Developing and Testing a Care Pathway for Patients Discharged From an Intensive Care Unit

RESEARCH QUESTION Can an evidence-based, theoretically driven, electronically-enabled, in-hospital Enhanced Recovery After Critical Care (ERACC) pathway increase hospital-free days (HFD) following discharge from an intensive care unit (ICU)?

BACKGROUND Over 14,000 (one in ten) patients discharged from UK ICUs unexpectedly either die on the ward or are readmitted to an ICU annually. After hospital discharge, 31% are readmitted acutely within three months. These poor outcomes occur despite strong evidence of avoidability.

Over three-quarters of UK ICUs provide post-ICU follow-up care, but the care provided is highly variable and lacks evidence of clinical and cost effectiveness. The NIHR-funded REFLECT study, in combination with other work suggests key areas for effective intervention.

An evidence-based ERACC pathway has the potential to increase effectiveness and efficiency, and reduce inequalities from practice variation.

AIM To develop, refine, implement and test an ERACC pathway to increase the number of HFDs following discharge from an ICU.

OBJECTIVES To: describe current and aspirational UK ICU follow-up practice define key ERACC intervention components define the work required to deliver the combined ERACC interventions iteratively develop the ERACC pathway (core intervention) 3-site Feasibility study Evaluate the ERACC pathway in a cluster-randomised 16-centre study complete a process evaluation assess patient-centred clinical and health economic outcomes report a refined programme theory METHODS WORK PACKAGE 1 A UK-wide survey of current in-hospital critical care follow-up services and Focused ethnographic observations and qualitative interviews will allow in-depth description of current and aspirational ICU follow-up practice and identification of barriers/facilitators to ERACC provision/normalisation.

WORK PACKAGE 2 Evidence syntheses utilising prior REFLECT work and new literature reviews will identify potential intervention areas and summarise methods underlying prior successful intervention components, will inform: A three-round Delphi process defining key ERACC interventions.

WORK PACKAGE 3 A three-centre cohort study documenting post-ICU care requirements to deliver the key ERACC interventions will define in detail the work required to deliver the ERACC.

WORK PACKAGE 4 Three-site stakeholder interviews and focus groups Functional Resonance Analysis Method of clinical interventions Iterative logic model development Electronic pathway development Three-site care electronically supported pathway iteration Three-site feasibility study will deliver an electronically-enabled ERACC with reliable high fidelity, dose and reach, reducing practice variation.

WORK PACKAGE 5 16-centre cluster randomised controlled trial with evaluation of: Clinical outcome impact Health economic impact Process will evidence ERACC pathway implementation and provide a final programme theory.

WORK PACKAGE 6 With our PPI group, findings will be disseminated and implemented through: Our integration within the National Outreach Forum, Intensive Care Society National Rehabilitation Collaborative and NHSE Adult Critical Care Rehabilitation Outcomes group Patient groups (lay summaries, newsletters infographics) Journals and conferences An accessible public website and social media TIMELINES 72 months – see GANTT IMPACT A protocolised, evidenced ERACC pathway will deliver structured, safer care.

If successful, this may result in over 250,000 extra HFDs for UK ICU survivors each year.

Our patient-centred outcome, health economic evaluation and integration with key delivery groups are designed to deliver rapid implementation.