Table 4 Detailed description of the rehabilitation construct adapted from recommendations from wells and colleagues[29], the Medical Research Council framework[27], and the modified CONSORT guidance for randomised controlled trials of non-pharmacologic randomised controlled trials[28]

Stage one – ICU discharge

Introduction of patient to GRA, initial assessment, and explanation of rehabilitation strategy

To establish relationship between GRA and patient

Initial meeting

Early commitment to provide individualised rehabilitation and information will promote engagement, trust and reassurance, and reduce perception of abandonment

Low

Low

GRAs together with existing rehabilitation teams (primarily physiotherapy and dietetics)

GRA competency-based training in assessment and awareness of common ICU problems

General ward; occasionally in the ICU prior to discharge

As soon as feasible following allocation to intervention group

Provide information to patient and carer

Formal assessment of function

Timing to suit patient, but within 1 day of randomisation in most cases

Setting initial rehabilitation goals

Meeting between patient and ICU consultant, with involvement of GRA and family where appropriate

To provide information about ICU stay and likely problems during recovery

Scheduled meeting

Information will reduce stress and anxiety

Moderate

Moderate

ICU consultant.

ICU consultant familiar with topic guide, knowledge of generic post-ICU issues and the individual patient history

General ward

During the first week or when deemed most appropriate by the GRA

Opportunity for patients and family to ask questions

Topic guided discussion to cover physical and psychological sequelae of critical illness¹

Filling in gaps and exploring delusional memories may reduce psychological morbidity

Optional; patient may decline meeting

Meeting usually attended by GRA

Answering questions and providing realistic expectations may help adjustment

Meeting tailored to individual patient and family

Provision of lay summary of ICU stay

Provide information about ICU stay and likely problems during recovery in understandable format

Lay summary dictated by consultant familiar with patient history using standard proforma²

Information in summary will achieve similar outcomes to the consultant visit and/or consolidate information given

Moderate

Low

ICU consultant to generate summary

ICU consultant familiar with topic guide, knowledge of generic post-ICU issues and the individual patient history

General ward

During post-ICU hospital stay

Written summary can be used as ongoing resource by patient and family

All patients provided with summary, but decision regarding how and when to read this and use it at patient discretion

GRA to provide it to the patient, often with additional explanation

GRA with relevant training to assist patient in understanding content if needed

Posted to patient post-discharge if not available prior to hospital discharge

Important as poor memory and other cognitive impairments may limit retention of information from meeting

Provision of self-help rehabilitation manual

Provide a resource to support recovery process

Manual that improved physical recovery in a previous randomised controlled trial³

Supported use of the self-help manual improved physical function components of quality of life questionnaires when used during the first 2 months following ICU discharge

Moderate

High

GRA

GRA familiar with the content and goals of the manual

General ward

Early during the post-ICU stay

Manual provided to all patients

Use tailored to individual patients

Stage two –Ward-based rehabilitation

Regular assessment by GRA

To assess patients using a combination of clinical judgement and standardised screening tools in relation to:

Frequent assessment and reassessment

A regular structured approach by a single individual to identify problems across multiple areas that potentially contribute to disability will improve coordination of care by senior rehabilitation staff who often working separately

Moderate

Moderate

GRA

GRA trained to defined competencies in each area

General ward

Throughout acute hospital stay

Physical function. Nutritional status and dietary intake

Use of screening tools to trigger specialist advice from: physiotherapy, dietetics, occupational therapy, and speech and language therapy⁴

Consistency across multiple relevant areas will reduce the chance of one unaddressed issue slowing overall recovery

Frequency and timing of formal assessments and use of screening tools at discretion of GRA, but expected to occur weekly

Screening and assessment largely undertaken by GRA

GRA trained in use of screening tools

Activities of daily living

Informal assessment on more frequent basis

Communication and swallowing

Individualised goal setting

To set achievable realistic rehabilitation goals, individualised to each patient

Documented individualised goals agreed between rehabilitation team and patient

Individualised goal-setting is effective in other rehabilitation settings

High

High

GRAs and senior specialist rehabilitation staff as necessary

Training in the use of goal-setting in rehabilitation settings

General ward

Throughout acute hospital stay

Regularly revised

Allows patient to focus on issues important to them

Intention to define achievable goals approximately weekly, but adjusted to individual patients

Potentially other settings (home visits; trips to other areas)

Patient feels empowered and involved

Achieving goals and documenting progress may have additional beneficial effects on psychological morbidity

Therapy sessions

Provide therapy sessions designed to achieve rehabilitation goals

Individually tailored therapy in areas of: Physiotherapy

Physiotherapy will improve the prominent symptomatology, and restore abilities to undertake ADL

High

High

GRA

Competency-based training in all relevant areas

General ward

Throughout acute hospital stay

Dietetics

Dietetic therapy will address weight loss and barriers to nutritional recovery, such as poor appetite

Discrepancy between intended therapy and treatment achieved by patient strongly influenced by patient fatigue, mood, delirium, and many other issues

Planning and advice from senior rehabilitation specialists

Physiotherapy department

Timing and frequency determined by GRA and rehabilitation teams. Target at least one session per day from GRA monday to friday

Occupational therapy

Occupational therapy will restore ability to undertake ADLs, reduce disability, and improve independence

Variable amount of therapy provided by senior specialists according to individual need

Occupational therapy department

Speech and language therapy

Speech and language therapy will treat specific swallowing problems or communication issues

Other hospital areas (stairs and mobility)

Pre-defined sub-types of therapy to capture the processes that occurred in each session or patient encounter

Coordinated approach to therapy will reduce disability, improve quality of life, and may decrease psychological morbidity.

Offer visit to the ICU

May help with memories and adjustment to health status

Accompanied visit to ICU with GRA, medical staff, and family according to patient preference

ICU visit may help fill in gaps for some patients

High

High

GRA plus other staff according to patient preference

GRA familiar with individual patient history, and trained in common psychological morbidity and memories of ICU

ICU in which patient was cared for

Any time during acute hospital stay, or after hospital discharge if preferred

May help with adjustment to illness or dealing with dreams and delusional memories

ICU visit optional

May reduce psychological issues

Timing to suit individual patient

Stage three – Hospital discharge planning

Liaison with ward-based staff to ensure equipment and community referrals are in place before discharge home

Ensure services and equipment are in place during the transition from hospital to the community

Liaison between the GRA and other healthcare professionals to ensure services and equipment are in place at discharge

Ensure patient has correct services and equipment in place at home for discharge

Moderate

Moderate

GRA and other healthcare staff depending on patient needs

GRA familiar with patient history and social/home circumstance

General ward

Throughout ward stay to allow planning but in particular in the time leading up to discharge from hospital

Ensuring patient is as supported at possible at the time of discharge from hospital

Stage four – Post-hospital discharge

Provide contact details for GRA

A single point of contact to coordinate help if patient not coping in the community

Provide mobile phone number and advice to contact if required

Many patients are discharged home with significant disability

Moderate

Moderate

GRA

GRA familiar with individual patient case history

Community

Following hospital discharge at discretion of GRA

Telephone patient at least once following discharge

A topic guide to ensure all issues are covered

Patients and families often uncertain where to turn for help

All patients and families will receive contact details

Trained to mobilise relevant hospital and community teams as required

Unsolicited contact within 1 week of discharge

Ensure any equipment and community referrals are in place

Single point of contact to individual who knows their history well will enable rapid identification of problems and solutions

All patients will receive one unsolicited contact

Ongoing contact available until primary outcome measurement

This will reduce patient/family stress, decrease chance of emergency readmission, and improve efficiency of use of community rehabilitation teams

Numbers of subsequent contacts determined by patient and family

GP discharge summary (example proforma included in Additional file 1)

A discharge summary completed by the GRA to provide additional information to GPs about the impact of the critical illness on the patient

A summary of functional ability across physiotherapy, occupational therapy, dietetics and speech and language therapy

GPs often only manage 1 to 2 patients a year that suffer a critical illness

High

Low

GRA

GRA familiar with the individual patient case history and status at the time of discharge

Office-based activity

Immediately following hospital discharge

A short summary of psychological function

This information will increase their knowledge about the specific issues faced by the individual patient after a critical illness

All discharge summary letters will be completed with patient specific detail

A summary of community referrals made

The additional general information about common sequelae after critical illness will increase the GPs general knowledge of the issues faced by patients after critical illness and facilitate the identification of any issues that arise after discharge and can be managed by the GP

All summaries will include standard information about the general sequelae after critical illness

Information about typical physical and psychological sequelae after critical illness