Elsevier

Journal of Critical Care

Volume 46, August 2018, Pages 141-148
Journal of Critical Care

Outcomes/Predictions
Comprehensive care of ICU survivors: Development and implementation of an ICU recovery center

https://doi.org/10.1016/j.jcrc.2018.02.011Get rights and content

Highlights

  • An outpatient intervention for recovery after critical illness (ICU Recovery Center) is proposed.

  • The development, implementation, and characteristic patient population of an ICU-RC in the United States is described.

  • A pragmatic clinical population of patients recovering from critical illness had a range of impairments after discharge.

  • Post-ICU recovery programs have not been widely studied or adopted despite the scope of these problems.

  • An ICU-RC is feasible and has the potential to minimize post intensive care syndrome (PICS) and maximize recovery.

Abstract

Purpose

To describe the design and initial implementation of an Intensive Care Unit Recovery Center (ICU-RC) in the United States.

Materials and methods

A prospective, observational feasibility study was undertaken at an academic hospital between July 2012 and December 2015. Clinical criteria were used to develop the ICU-RC, identify patients at high risk for post intensive care syndrome (PICS), and offer them post-ICU care.

Results

218/307 referred patients (71%) survived to hospital discharge; 62 (28% of survivors) were seen in clinic. Median time from discharge to ICU-RC visit was 29 days. At initial evaluation, 64% of patients had clinically meaningful cognitive impairment. Anxiety and depression were present in 37% and 27% of patients, respectively. One in three patients was unable to ambulate independently; median 6 min walk distance was 56% predicted. Of 47 previously working patients, 7 (15%) had returned to work. Case management and referral services were provided 142 times. The median number of interventions per patient was 4.

Conclusions

An ICU-RC identified a high prevalence of cognitive impairment, anxiety, depression, physical debility, lifestyle changes, and medication-related problems warranting intervention. Whether an ICU-RC can improve ICU recovery in the US should be investigated in a systematic way.

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.

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