COVID-19：重症监护后患者康复的挑战
BMJ2020;369doi:https://doi.org/10.1136/bmj.m1787(Published 06 May 2020)引用这是：BMJ2020;369：m1787linked patient perspective
我担心Covid-19患者会因裂缝而掉落
linked patient perspective
在7周内，我一直经历过不良健康，极端情绪和完全疲惫的过山车
linked patient perspective
there may be greater need for rehabilitation after a covid-19 ICU stay
Covid-19 has shone a bright light on the impressive work of NHS intensive care units (ICUs) around the UK. Now, as the first patients who have had the new virus and spent days ventilated in ICUs are discharged, the Chartered Society of Physiotherapy predicts a “tsunami of rehabilitation needs.”
一个lready there are question marks about whether appropriate rehabilitation—physical, cognitive, and psychological—will be available for the huge numbers of people who will need to deal with the enormous impact of a stay in critical care.
心脏病发作，创伤或中风后的康复已经建立了良好的途径。但是，对于每年在重症监护中度过时光的成千上万人的康复不是自动的，尽管严重的肌肉浪费和解剖，睡眠障碍和严重的疲劳，记忆问题，焦虑，抑郁症，抑郁症和创伤后应激障碍。1这些“普通” ICU患者可能是该国最病人，但是一旦离开，他们可能会得到最少的支持。
缺乏清晰度和访问的一致性
In 2017 the National Institute for Health and Care Excellence set out quality standards for adults after critical illness,2受到专家的欢迎。但是，由于没有一致收集的标准化数据，因此很难说有多少需要这种康复的人接受它。在英格兰，威尔士和北爱尔兰，2018 - 19年向263 NHS成人重症监护病房进行了约224 748次入院。3Experts suggest that two thirds of such patients would need some kind of rehabilitation.
One area where data are collected is pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD), which is offered to only 13% of eligible patients despite good evidence.4there is also regional variability: five hyperacute regional inpatient specialist rehabilitation units take patients directly from the ICU, and some individual trusts have developed excellent services for early post-ICU outpatient rehabilitation.
Elsewhere it is patchy, sometimes simply consisting of a nurse doing a one-off telephone follow-up. The biggest barrier is variability in funding despite evidence of cost effectiveness.5
康复重点与COVID-19
Covid-19 has forced NHS England and individual trusts to think about rehabilitation with some urgency. Karen Middleton, chief executive of the Chartered Society of Physiotherapy, says, “Rightly, so far, the focus has been saving lives—but, as the first wave of patients begin to recover, the scale of the next phase is becoming clear.”
Patients with the virus seem to be ventilated for far longer than the average ICU patient, causing higher levels of deconditioning, and there are more of them at any one time. Evidence from China shows that covid-19 patients have neurological as well as respiratory after effects,6因此，恢复将更长，更复杂。英国政府预测，有45％的患者将需要某种形式的低水平医疗或社会投入才能恢复，而4％的患者将需要在床位的环境中更加专注，持续的强烈康复。7lynne Turner-Stokes, consultant in rehabilitation medicine, says, “We need all of those different levels of service. And, importantly, we need them to be joined up.”
卡尔·沃尔德曼（Carl Waldmannbox 1）。He says that, as ICU demand has tripled, we will see a corresponding bulge in the need for rehabilitation. “It shouldn’t have taken a pandemic,” he says, “but I think it will make people realise the problems you may have after a period in intensive care, and the vital need for rehabilitation.”
Case study—Royal Berkshire Hospital
Intensive aftercare: the right to rehabilitation
这家医院每年为大约300名患者进行重症监护后，提供“密集的后期护理”。
如果患者在重症监护术上花费了四天或更长时间，或者由于突然疾病（例如过敏后手术或产后出血）而在那里呆了更短的时间。
they are first seen at an outpatient clinic two months after discharge and then again at six months and a year. At each stage they are assessed and may be further referred for physiotherapy, psychological help, memory help, ENT treatment, or post-traumatic stress counselling.
尽管成本是提供这些服务的障碍，但皇家伯克郡的重症监护医学顾问卡尔·沃尔德曼（Carl Waldmann会议。
He explains, “Our total budget for critical care would probably be something like £8m. You’re looking at a minute fraction of that—something like £100 000—depending on the numbers of patients.”
Such is the success of this service, as well as seeing its own former ICU patients it sees patients who have been treated in other hospitals and referred by GPs. Waldmann says, “GPs are slowly coming on board. At first, they didn’t feel it was necessary. Now they actually refer patients that have not had follow-up at other hospitals to our hospital.”
melanie Gager, ICU nurse consultant, is adamant that covid-19 patients should benefit too. “Offering rehab is not an option—it is a necessity,” she says. “It will be challenging and require increased resources, but these patients must be given the right to rehab.”
Covid recovery plans and prescriptions
重症监护协会（ICS）和英国康复医学学会一直在与NHS England合作，紧急制定即将发布的Covid-19-19恢复计划。皇家伦敦医院重症监护术的名誉顾问Zudin Puthucheary，伦敦皇后大学的高级讲师，正在从ICS方面领导。他说，Covid-19患者进行康复的推动将是“改善所有ICU患者护理的机会”。
一个t Northwick Park Hospital in northwest London, the 24 bed regional hyperacute rehabilitation unit has not yet seen many covid-19 patients. Instead it has taken in more non-covid patients from other ICUs in London to free up capacity. Turner-Stokes, the unit’s director, says that it is “waiting in the wings” to expand. But it has plans to record covid-19 patients’ ongoing needs and how they will be met in a “rehabilitation prescription,” as has been used for patients in trauma rehabilitation.
她希望这将记录在与创伤类似的国家临床审核中，以证明对服务的需求。8特纳·斯托克斯（Turner-Stokes）说：“有一个非常积极的机会可以学习从COVID-19的不同方式做事的方式。”
心理支持和GP意识
Early indications suggest that covid-19 patients will need even more psychological support than typical ICU patients because of higher levels of “survivors’ guilt” and post-traumatic stress disorder.
在皇家伯克郡，专门从事重症监护的护士顾问沃尔德曼的同事梅兰妮·加格（Melanie Gager）说：“他们正在醒来，看到其他人在他们面前垂死，知道他们都出于同样的原因而在那里。”她补充说，由于无尽的媒体报道，他们离开医院时没有“逃脱”。这导致他们问：“为什么我？”尽管在败血症患者中也可以看到，但并不是典型的队列。
特许理疗的特许社会担心，重点将不可避免地放在提供足够的康复上，以将人们沿着这条路移动，但是当人们回家时，这将是“看不见的，令人看不见的问题”。因此，全科医生需要意识到ICU和康复需求的巨大影响。在Covid-19之前，普通的全科医生会看到有人每两到三年一次参加一次ICU。皇家伯克希尔（Royal Berkshire）麻醉和重症监护医学顾问克里斯·丹伯里（Chris Danbury）说：“这是一个完全超出了GPS的经验。”
重症监护顾问兼英国败血症基金会执行董事罗恩·丹尼尔斯（Ron Daniels）表示，出院文件信必须非常明确和清晰，“为了传达我们期望患者将需要长期存在的身体，心理和认知问题支持和关注。”
louise Worrall, inpatient physiotherapy lead at Milton Keynes University Hospitals Trust, says that rehabilitation must be given to justify the original treatment (box 2）。她问：“为什么要投入这么多的ICU时间和资源来挽救生命，然后让患者患有令人衰弱的症状，而家人则不知道该怎么做才能使任何事情变得更好？我们必须恢复这些患者，以尽可能优化康复，将他们返回更广泛的社会，您可以争辩说，证明在ICU中给他们的巨大资源是合理的。”
案例研究-Milton Keynes University Hospitals Trust
Eight weeks of gym sessions
在这里，通风超过三天的患者可以使用康复，或者不被通风的患者可用，其长度约为一周或更长时间。医院通过电话提供一对一的约会和支持。
它还举办每周赛区康复健身based, eight week minimum programme of cardiovascular exercise and strengthening, with specific individual goals.
“While there is still potential for further recovery, we keep going. The group is amazing,” says Louise Worrall, inpatient physiotherapy lead. “To watch them all completing their exercise circuits on the exercise bike or treadmill, and remembering where they were just a few weeks before on a ventilator, is quite something!”
Worrall预计Covid-19患者的康复“与现有服务相同的线条非常相同”，但需求的两倍。
She says, “The challenges for us will be the number that are likely to need rehab at the same time. We have never seen this many sick patients requiring such prolonged ventilation.”
案例研究 - 斯旺西莫里斯顿医院
One-to-one rehabilitation advanced with pilot
Every patient in Morriston’s ICU for three days or more is referred to a follow-up clinic comprising a consultant and physiotherapist, who act as a triage to further services such as occupational therapy or musculoskeletal, psychological, or community support.
the hospital also offers a six week, twice weekly, one-to-one rehabilitation programme, which has been running for 10 years. Karen James, clinical lead physiotherapist for critical care, says, “Unlike cardiac rehab or pulmonary rehab where you can all go to a class together, our patients can be a 70/80 year old COPD and a 19 year old road traffic accident, so they’re not going to have the same types of needs. So, we offer a one-to-one session which they can come to on a day they like, at a time they like.”
现在，这些服务正在进一步发展：他们为飞行员赢得了资金，在该飞行员中，Physio Rehabilitation技术人员在ICU上介绍了重症监护患者，然后才踩到另一个病房。
他们会跟随他们在那里和家里，因为恢复学习9建议他们一旦从ICU辞职后可以减少康复。该计划从下个月开始，詹姆斯说，Covid-19患者将是“理想的候选人”。她补充说：“他们将有很多神经病和弱点，因为它们已经瘫痪和镇静了很长时间，因此它们将非常虚弱。”
脚注
竞争利益：我已经阅读并理解了关于宣言利益的BMJ政策，并且没有相关的利益可以宣布。
出处和同伴观点：委托；没有外部同行评审。