Outcomes/PredictionsComprehensive care of ICU survivors: Development and implementation of an ICU recovery center☆
Introduction
Over 6 million patients become critically ill each year. Of these, an increasing number will survive due to advances in critical care [1]. This survival is not without cost. As the long term effects of critical illness become known, the need to design and implement effective interventions to rescue critical illness survivors from incomplete recovery has become a pressing priority for many clinicians. However, evidence based guidelines for intensive care unit (ICU) follow up and recovery remain elusive. In 2012, we started seeing patients in an outpatient team clinic designed to screen for and treat Post Intensive Care Syndrome (PICS), with the goal of promoting recovery for the sickest patients who survive the ICU. This effort was inspired by a patient in the Vanderbilt Medical ICU, and was undertaken as a pragmatic clinical intervention in an attempt to address the multifaceted yet ICU-specific problems emerging in the literature and in practice.
At the time, there was little to guide us in the development of an ICU follow up program. ICU survivors have high rates of mortality and increased health care utilization following discharge [[2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]]. The rise in survivorship has created a burgeoning population suffering from long-term consequences of critical care [[13], [14], [15], [16], [17], [18]], including cognitive impairment [[18], [19], [20], [21], [22], [23]], anxiety [[16], [17], [18]], depression [13,[15], [16], [17], [18]], post-traumatic stress disorder [[13], [14], [15], [16], [17], [18],24], decreased quality of life [9,12,[25], [26], [27], [28], [29]], and physical disability [17,20,30,31]. This constellation of problems is now known as PICS, a condition of new or worsening dysfunction in key domains such as cognition and physical function that persists beyond the inciting critical illness [32]. Despite the success of survivorship programs in the treatment of other populations [33] and a call for action to improve the lives of ICU survivors [34,35], there are few programs aimed at decreasing morbidity and mortality in the post ICU recovery period in the United States (US).
Early attempts in the United Kingdom (UK) and Scandinavia were conducted in very different health care environments, with different providers (primarily advanced practice nurses), and distant from the index hospitalization [[36], [37], [38], [39]]. The most commonly studied outcome was health related quality of life (typically defined by outcome measures that may or may not correlate with patient's “real world” concerns), and in this domain an ICU follow up program did not appear to have significant effect. In recent years, interest in real world approaches to caring for ICU survivors has continued to grow, but the interventions and outcomes needed in this population remain unproven [[40], [41], [42], [43]]. In our tertiary US medical center, complex medical patients are often uninsured, or otherwise lacking in the support structures necessary for a successful recovery, including a preexisting relationship with a primary care physician. The concept of a post intensive care syndrome was not (and still is not) widely known nor understood by patient, families, and medical providers. And, the specialists or interventions that might prove effective in remediating the deficits experienced by patients after the ICU were not understood.
In an attempt to increase our understanding and outline the most pressing needs in the post-ICU period, we spoke with current and former patients, study participants, family members, and health care providers. We assembled some of the same team members who work closely together to care for patients in the ICU, and translated their expertise to the outpatient setting. Then, we identified patients thought to be at highest risk for post-ICU complications by the clinical criteria that were known in the literature at the time: septic shock; lung injury, especially when treated with mechanical ventilation, and delirium [2,8,14,15,20,23].
Section snippets
Clinic description
The ICU Recovery Center (ICU-RC) at Vanderbilt opened in 2012. The genesis of this clinic was grounded in clinical and research insights dating back at least a decade and borrowed elements from other successful team clinic models, notably those addressing cancer survivorship; there are over 300 of these highly specialized clinics in North America, where they are now considered standard care. Patients with severe critical illness, as indicated by mechanical ventilation, sepsis or septic shock,
Study design and participants
We conducted a prospective, observational feasibility study of adults referred to a pragmatic clinical pilot program, the ICU-RC, at a tertiary care center (VUMC) between July 2012 and December 2015. Eligible patients were critically ill adults ≥18 years old with one or more risk factors for the development of PICS, including sepsis, delirium, or respiratory failure requiring mechanical ventilation. Patients were excluded for terminal illness with life expectancy <6 months, hospice referral or
Results
Of 307 referrals, 62 patients completed a visit to the ICU-RC. Patients were referred from 5 types of ICUs; 90% were from the medical ICU and were referred by ICU-RC team members. Patient recruitment is outlined in Fig. 1.
Discussion
An ICU-RC is feasible and provides opportunity to maximize recovery and minimize the adverse effects of critical illness in a high-risk population. We observed a high prevalence of impairments including cognitive deficits, disorders of anxiety and mood, physical debility, medication related problems, and changes in lifestyle with the potential to affect socioeconomic status, underscoring the magnitude of difficulties patients experience in the early post ICU discharge period.
Existing data
Financial support
The project described was supported by CTSA award No. UL1 TR002243 from the National Center for Advancing Translational Sciences, the Vanderbilt Division of Allergy, Pulmonary and Critical Care Medicine, and the Vanderbilt Department of Pharmaceutical Services.
Conflicts of interest and sources of funding
Carla M. Sevin, Sarah L. Bloom, James C. Jackson, and Li Wang have no conflicts of interest to disclose; E. Wesley Ely has received honoraria for CME activities from Pfizer, Abbott, and Orion; Joanna L. Stollings has no conflicts of interest to disclose.
Acknowledgements
CMS and JLS had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the analysis. CMS, SLB, JCJ, LW, EWE, and JLS contributed substantially to the study design, data analysis and interpretation, and the writing of the manuscript. Arthur Wheeler provided invaluable mentorship in establishing the ICU Recovery Center at Vanderbilt while acting as medical director for the Medical Intensive Care Unit at Vanderbilt University Medical Center.
References (70)
- et al.
Critical care and the global burden of critical illness in adults
Lancet
(2010) - et al.
The relationship between executive dysfunction, depression, and mental health-related quality of life in survivors of critical illness: results from the BRAIN-ICU investigation
J Crit Care
(2017) - et al.
Screening and treatment of problems after intensive care: a descriptive study of multidisciplinary follow-up
Intensive Crit Care Nurs
(2011) - et al.
Outcomes of nurse practitioner-delivered critical care: a prospective cohort study
Chest
(2016) - et al.
Psychometric properties of the PTSD checklist (PCL)
Behav Res Ther
(1996) - et al.
Rosuvastatin versus placebo for delirium in intensive care and subsequent cognitive impairment in patients with sepsis-associated acute respiratory distress syndrome: an ancillary study to a randomised controlled trial
Lancet Respir Med
(2016) - et al.
Three-year outcomes for medicare beneficiaries who survive intensive care
JAMA
(2010) - et al.
Determinants of long-term survival after intensive care
Crit Care Med
(2008) - et al.
Five-year mortality and hospital costs associated with surviving intensive care
Am J Respir Crit Care Med
(2016) - et al.
Increased 1-year healthcare use in survivors of severe sepsis
Am J Respir Crit Care Med
(2014)
Late mortality after sepsis: propensity matched cohort study
BMJ
Long-term outcomes and healthcare utilization following critical illness--a population-based study
Crit Care
One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study
AnnInternMed
Opening the door: the experience of chronic critical illness in a long-term acute care hospital
Crit Care Med
ProVent study group I: the epidemiology of chronic critical illness in the United States*
Crit Care Med
Surviving intensive care: a systematic review of healthcare resource use after hospital discharge*
Crit Care Med
Scottish critical care trials G, Scottish Intensive Care Society audit G: mortality and quality of life in the five years after severe sepsis
Crit Care
The RECOVER program: disability risk groups and 1-year outcome after 7 or more days of mechanical ventilation
Am J Respir Crit Care Med
Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care
Crit Care Med
Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study
Lancet Respir Med
Blood institute acute respiratory distress syndrome N: psychiatric symptoms in acute respiratory distress syndrome survivors: a 1-year National Multicenter Study
Crit Care Med
Long-term outcomes after severe shock
Shock
The adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological function in survivors of acute lung injury
Am J Respir Crit Care Med
Long-term cognitive impairment after critical illness
N Engl J Med
Long-term cognitive impairment and functional disability among survivors of severe sepsis
JAMA
Cognitive dysfunction after critical illness: measurement, rehabilitation, and disclosure
Crit Care
Cognitive dysfunction in ICU patients: risk factors, predictors, and rehabilitation interventions
Crit Care Med
Delirium as a predictor of long-term cognitive impairment in survivors of critical illness
Crit Care Med
Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care
Intensive Care Med
Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome
Am J Respir Crit Care Med
Survivors of acute respiratory distress syndrome: relationship between pulmonary dysfunction and long-term health-related quality of life
Crit Care Med
Quality of life after acute respiratory distress syndrome: a meta-analysis
Intensive Care Med
Quality of life in the five years after intensive care: a cohort study
Crit Care
Functional disability 5 years after acute respiratory distress syndrome
N Engl J Med
Physical and cognitive performance of patients with acute lung injury 1 year after initial trophic versus full enteral feeding. EDEN trial follow-up
Am J Respir Crit Care Med
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Institution Where Research Performed: Vanderbilt University Medical Center, Nashville, TN.