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The REcovery FoLlowing Intensive CarE Treatment (REFLECT) research programme was funded by a grant awarded by the NIHR Research for Patient Benefit scheme. The first phase of this work is now complete and the results are being used to inform development of a complex intervention to improve post-ICU ward care.


A substantial number of patients discharged from Intensive Care Units (ICUs) subsequently die without leaving hospital. It is unclear how many of these deaths are preventable. Ward-based management following discharge from ICU is an area that patients and healthcare staff are concerned about. The primary aim of REFLECT (Recovery Following Intensive Care Treatment) was to develop an intervention plan to reduce in-hospital mortality rates in patients who have been discharged from ICU.

REFLECT was a multicentre mixed methods exploratory study examining ward care delivery to adult patients discharged from ICU. The study was made up of four sub-studies. Medical notes of 300 patients who were discharged from intensive care and subsequently died were examined using a Retrospective Case Records Review (RCRR) technique. Interviews were also conducted with 55 participants. Patients and their relatives were interviewed about their post-ICU care, including relatives of patients who died in hospital following ICU discharge. Staff involved in the care of patients post-ICU discharge were interviewed about the care of this patient group. The medical records of 40 patients who either survived their post-ICU stay or did not survive and had problems in their care were also reviewed using the RCRR and in-depth analysis. The evidence generated in these four sub-studies will form the basis of the intervention development, which will take place through stakeholder and clinical expert meetings.   

Project Publications

The first paper from the REFLECT team reported a meta-analysis of out-of-hours discharge from intensive care, which formed part of the background work to the project. Published in Intensive Care Medicine.

The protocol was published in BMJ Open.

The structured judgement review identified that probably avoidable deaths are higher in post-ICU patients than general hospital populations, and identified common problems in care related to these avoidable deaths:

Problems in care and availability of death after discharge from intensive care: A multi-centre retrospective case record review study

We identified problems with prioritisation of rehabilitation interventions on the ward:

A human factors analysis of missed mobilisation after discharge from intensive care. A competition for care?

Out-of-hours discharge was a common problem which impacts patient safety on the ward:

Patient harm and institutional availability of out-of-hours discharge from intensive care: An analysis using mixed methods

Nutrition is an important part of rehabilitation following critical illness but we found multiple problems with supporting adequate nutrition following discharge from ICU:

Opportunities to improve nutrition delivery in hospital after discharge from an intensive care unit: A mixed methods analysis


REFLECT was also shortlisted for the Intensive Care Society gold medal award and presented at ICS State of the Art 2019.

Lay summary

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.


Contact details for the REFLECT study

The REFLECT study is managed and co-ordinated by Sarah Vollam and Owen Gustafson.