ICU Recovery Clinic Attendance, Attrition, and Patient Outcomes: The Impact of Severity of Illness, Gender, and Rurality

"How Do I Test the Waters? How Do I Go Forward?": Codesigning a Supportive Pathway after Critical Illness

Rationale: Long-term recovery after critical illness can be affected by post-intensive care syndrome (PICS), a significant burden, which can impact return to activities and work. There is a need for streamlined support for intensive care unit (ICU) patients in their recovery while enduring PICS symptoms. Objectives: To explore critical illness recovery from the experiences, perspectives, and beliefs of former ICU patients, their caregivers, and multidisciplinary clinicians to design a future rehabilitation intervention prototype to support ICU patients. Methods: This was an experience-based codesign (EBCD) study underpinned by the Behavior Change Wheel framework involving ICU patients (<5 years after illness), caregivers, and multidisciplinary clinicians with current clinical experience with ICU recovery at any point along the care continuum (ICU, acute, subacute, or community settings) from two metropolitan hospitals in Melbourne, Australia. Two rounds of experience-based codesign workshops were held between August 2021 and February 2022. Workshop content was analyzed via a reflective thematic approach to determine themes and develop an intervention. The intervention was mapped according to the template for intervention description and replication framework. Results: Forty people participated in the codesign process: 15 ICU patients, 2 caregivers, and 23 clinicians. Fifteen major themes were identified in the experience of ICU recovery. Returning home was a key time point for change, acceptance, and adjustment, with the burden of physical limitations and mental health problems becoming apparent. Most participants expressed that PICS was poorly understood in the community, and there was a lack of support to aid recovery. Based on these results, an intervention prototype was developed with a primary goal of improving care after hospital discharge. This was further refined in the second round of workshops. A resource toolkit was deemed most acceptable to end-users, including a hospital-directed support program involving psychology and physical therapy and an accompanying digital health package. Conclusions: A critical time point for more support in the recovery journey was the transition from hospital to home. To address this, a rehabilitation prototype including a physical and psychological support intervention and supporting digital health toolkit was codesigned. The intervention package will be developed and trialed with future ICU patients and their families. Clinical trial registered with www.clinicaltrials.gov (NCT05044221).

Models of intensive care unit follow-up care and feasibility of intervention delivery: A systematic review

BACKGROUND

The optimal model of outpatient intensive care unit (ICU) follow-up care remains uncertain, and there is limited evidence of benefit.

RESEARCH QUESTION

The objective of this research is to describe existing models of outpatient ICU follow-up care, quantify participant recruitment and retention, and describe facilitators of patient engagement.

STUDY DESIGN & METHODS

A systematic search of the MEDLINE and EMBASE databases was undertaken in June 2021. Two independent reviewers screened titles, abstracts, and full texts against eligibility criteria. Studies of adults with any outpatient ICU follow-up were included. Studies were excluded if published before 1990, not published in English, or of paediatric patients. Quantitative data were extracted using predefined data fields. Key themes were extracted from qualitative studies. Risk of bias was assessed.

RESULTS

A total of 531 studies were screened. Forty-seven studies (32 quantitative and 15 qualitative studies) with a total of 5998 participants were included. Of 33 quantitative study interventions, the most frequently reported model of care was in-person hospital-based interventions (n = 27), with 10 hybrid (part in-hospital, part remote) interventions. Literature was limited for interventions without hospital attendance (n = 6), including telehealth and diaries. The median ranges of rates of recruitment, rates of intervention delivery, and retention to outcome assessment for hospital-based interventions were 51.5% [24-94%], 61.9% [8-100%], and 52% [8.1-82%], respectively. Rates were higher for interventions without hospital attendance: 82.6% [60-100%], 68.5% [59-89%], and 75% [54-100%]. Facilitators of engagement included patient-perceived value of follow-up, continuity of care, intervention accessibility and flexibility, and follow-up design. Studies had a moderate risk of bias.

INTERPRETATION

Models of post-ICU care without in-person attendance at the index hospital potentially have higher rates of recruitment, intervention delivery success, and increased participant retention when compared to hospital-based interventions.

PROSPERO REGISTRATION

CRD42021260279.

Intensive care unit follow-up clinic activities: a scoping review

The importance of ongoing post-discharge follow-up to prevent functional impairment in patients discharged from intensive care units (ICUs) is being increasingly recognized. Therefore, we conducted a scoping review, which included existing ICU follow-up clinic methodologies using the CENTRAL, MEDLINE, and CINAHL databases from their inception to December 2022. Data were examined for country or region, outpatient name, location, opening days, lead profession, eligible patients, timing of the follow-up, and assessment tools. Twelve studies were included in our review. The results obtained revealed that the methods employed by ICU follow-up clinics varied among countries and regions. The names of outpatient follow-up clinics also varied; however, all were located within the facility. These clinics were mainly physician or nurse led; however, pharmacists, physical therapists, neuropsychologists, and social workers were also involved. Some clinics were limited to critically ill patients with sepsis or those requiring ventilation. Ten studies reported the first outpatient visit 1-3 months after discharge. All studies assessed physical function, cognitive function, mental health, and the health-related quality of life. This scoping review revealed that an optimal operating format for ICU follow-up clinics needs to be established according to the categories of critically ill patients.

Post-intensive care syndrome follow-up system after hospital discharge: a narrative review

BACKGROUND

Post-intensive care syndrome (PICS) is the long-lasting impairment of physical functions, cognitive functions, and mental health after intensive care. Although a long-term follow-up is essential for the successful management of PICS, few reviews have summarized evidence for the efficacy and management of the PICS follow-up system.

MAIN TEXT

The PICS follow-up system includes a PICS follow-up clinic, home visitations, telephone or mail follow-ups, and telemedicine. The first PICS follow-up clinic was established in the U.K. in 1993 and its use spread thereafter. There are currently no consistent findings on the efficacy of PICS follow-up clinics. Under recent evidence and recommendations, attendance at a PICS follow-up clinic needs to start within three months after hospital discharge. A multidisciplinary team approach is important for the treatment of PICS from various aspects of impairments, including the nutritional status. We classified face-to-face and telephone-based assessments for a PICS follow-up from recent recommendations. Recent findings on medications, rehabilitation, and nutrition for the treatment of PICS were summarized.

CONCLUSIONS

This narrative review aimed to summarize the PICS follow-up system after hospital discharge and provide a comprehensive approach for the prevention and treatment of PICS.

Mobile Critical Care Recovery Program for Survivors of Acute Respiratory Failure: A Randomized Clinical Trial

Importance

Over 50% of Acute Respiratory Failure (ARF) survivors experience cognitive, physical, and psychological impairments that negatively impact their quality of life (QOL).

Objective

To evaluate the efficacy of a post-intensive care unit (ICU) program, the Mobile Critical Care Recovery Program (m-CCRP) consisting of a nurse care coordinator supported by an interdisciplinary team, in improving the QOL of ARF survivors.

Design, Setting, and Participants

This randomized clinical trial with concealed outcome assessments among ARF survivors was conducted from March 1, 2017, to April 30, 2022, with a 12-month follow-up. Patients were admitted to the ICU services of 4 Indiana hospitals (1 community, 1 county, 2 academic), affiliated with the Indiana University School of Medicine.

Intervention

A 12-month nurse-led collaborative care intervention (m-CCRP) supported by an interdisciplinary group of clinicians (2 intensivists, 1 geriatrician, 1 ICU nurse, and 1 neuropsychologist) was compared with a telephone-based control. The intervention comprised longitudinal symptom monitoring coupled with nurse-delivered care protocols targeting cognition, physical function, personal care, mobility, sleep disturbances, pain, depression, anxiety, agitation or aggression, delusions or hallucinations, stress and physical health, legal and financial needs, and medication adherence.

Main Outcomes and Measures

The primary outcome was QOL as measured by the 36-item Medical Outcomes Study Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS), with scores on each component ranging from 0-100, and higher scores indicating better health status.

Results

In an intention-to-treat analysis among 466 ARF survivors (mean [SD] age, 56.1 [14.4] years; 250 [53.6%] female; 233 assigned to each group), the m-CCRP intervention for 12 months did not significantly improve the QOL compared with the control group (estimated difference in change from baseline between m-CCRP and control group: 1.61 [95% CI, -1.06 to 4.29] for SF-36 PCS; -2.50 [95% CI, -5.29 to 0.30] for SF-36 MCS. Compared with the control group, the rates of hospitalization were higher in the m-CCRP group (117 [50.2%] vs 95 [40.8%]; P = .04), whereas the 12-month mortality rates were not statistically significantly lower (24 [10.3%] vs 38 [16.3%]; P = .05).

Conclusions and Relevance

Findings from this randomized clinical trial indicated that a nurse-led 12-month comprehensive interdisciplinary care intervention did not significantly improve the QOL of ARF survivors after ICU hospitalization. These results suggest that further research is needed to identify specific patient groups who could benefit from tailored post-ICU interventions.

Trial Registration

ClinicalTrials.gov Identifier: NCT03053245.

The feasibility and acceptability of a physician-led ICU follow-up service: A prospective cohort study

BACKGROUND

Increased recognition of post-intensive care syndrome has led to widespread development of intensive care follow-up services internationally.

OBJECTIVE

The objective of this study was to determine the feasibility and acceptability of an intensive care unit (ICU) follow-up clinic in Australia for patients and their caregivers and to describe satisfaction with this service.

METHODS

This was a prospective cohort study in a mixed tertiary ICU in Australia. Eligible patients were adults admitted to the ICU for 7 days or more and/or ventilated for 48 h or more, as well as their primary caregiver. Patients and their primary caregivers were invited to attend a follow-up clinic 4-8 weeks after hospital discharge. The clinic appointment was attended by an ICU physician and nurse, with multidisciplinary support. Feasibility and acceptability were defined as the proportion of clinic attendance and frequency of interventions initiated at the clinic. Satisfaction was measured by a 5-point satisfaction survey (very dissatisfied to very satisfied). The burden of ongoing disease was reported via multiple validated instruments.

RESULTS

From April 2020-July 2021, 386 patients met the inclusion criteria. Only 146 patients were approached for consent due to site staffing limitations. Eighty-three patients and 32 caregivers consented to attend the clinic. Seventy percent (54/77) of patients attended scheduled appointments and 50% (16/32) of caregivers. For patients, 23 medical referrals were made, 8 patients had medication changes, and 10 patients were offered social work support. Satisfaction surveys were completed by 65% (35/54) of attending patients; 97% (34) patients reported either being 'very satisfied' or 'satisfied' with the service. All responding caregivers (10) were either 'very satisfied' or 'satisfied' with the clinic.

CONCLUSION

There were a large number of patients meeting the inclusion criteria to the ICU follow-up clinic, and clinic attendance was moderate for patients but lower for caregivers. Reported satisfaction with the service was high for both patients and their caregiver.

Do critical illness survivors with multimorbidity need a different model of care?

There is currently a lack of evidence on the optimal strategy to support patient recovery after critical illness. Previous research has largely focussed on rehabilitation interventions which aimed to address physical, psychological, and cognitive functional sequelae, the majority of which have failed to demonstrate benefit for the selected outcomes in clinical trials. It is increasingly recognised that a person's existing health status, and in particular multimorbidity (usually defined as two or more medical conditions) and frailty, are strongly associated with their long-term outcomes after critical illness. Recent evidence indicates the existence of a distinct subgroup of critical illness survivors with multimorbidity and high healthcare utilisation, whose prior health trajectory is a better predictor of long-term outcomes than the severity of their acute illness. This review examines the complex relationships between multimorbidity and patient outcomes after critical illness, which are likely mediated by a range of factors including the number, severity, and modifiability of a person's medical conditions, as well as related factors including treatment burden, functional status, healthcare delivery, and social support. We explore potential strategies to optimise patient recovery after critical illness in the presence of multimorbidity. A comprehensive and individualized approach is likely necessary including close coordination among healthcare providers, medication reconciliation and management, and addressing the physical, psychological, and social aspects of recovery. Providing patient-centred care that proactively identifies critical illness survivors with multimorbidity and accounts for their unique challenges and needs is likely crucial to facilitate recovery and improve outcomes.

Construct and criterion validity of muscle ultrasonography for assessment of skeletal muscle in patients recovering from COVID-19

Background: The purpose was to investigate the content, construct, and criterion validity of muscle ultrasound in a mixed cohort of participants recovering from mild and critical COVID-19. Methods: A secondary analysis of a prospective cross-sectional study was conducted on data obtained from a battery of muscle and physical function assessments including a muscle biopsy and muscle ultrasonography (US). Rectus femoris (RF) muscle thickness (mT), quadricep complex (QC) mT, RF muscle cross-sectional area (CSA) using 2D freeform trace and estimated from Feret's diameter, and RF echo intensity (EI) were assessed with US. Muscle fiber CSA, fiber type, protein content in muscle fibers, extracellular matrix content (ECM; wheat-germ agglutin), and percent area of collagen in ECM (picrosirius red) were examined from vastus lateralis muscle biopsies. Spearman rho correlations (r) were performed to assess validity of ultrasound parameters. Results: Thirty-three individuals participated including 11 patients surviving critical COVID-19, 15 individuals recovering from mild-COVID, and 7 controls. There were several significant correlations between RF mT, QC mT, RF CSA, and RF EI with age, comorbid burden, body-mass index, and measures of muscle strength, muscle power, and physical function (range r = 0.35-0.83). RF Feret's CSA correlated to CSA of type II muscle fibers (r = 0.41, p = 0.022) and the average size of all muscle fibers (r = 0.39, p = 0.031). RF EI was correlated with collagen in muscle ECM (r = 0.53, p = 0.003) and protein content in muscle tissue (r = -0.52, p = 0.012). Conclusion: Muscle size and quality measured using US has moderate content and construct validity, and to lesser extent, fair to moderate criterion validity in a mixed cohort of individuals recovering from COVID. Muscle ultrasound quality (EI) appears to be sensitive at detecting muscle dysfunction as it is associated with strength, power, physical function, and collagen distribution in a mixed group of individuals recovering from COVID-19.

Health system approaches to providing posthospital care for survivors of sepsis and critical illness

PURPOSE OF REVIEW

In the current review, we highlight developing strategies taken by healthcare systems to improve posthospital outcomes for sepsis and critical illness.

RECENT FINDINGS

Multiple studies conducted in the adult population over the last 18 months have advanced current knowledge on postdischarge care after sepsis and critical illness. Effective interventions are complex and multicomponent, targeting the multilevel challenges that survivors face. Health systems can leverage existing care models such as primary care or invest in specialty programs to deliver postdischarge care. Qualitative and implementation science studies provide insights into important contextual factors for program success. Several studies demonstrate successful application of telehealth to improve reach of postdischarge support. Research is beginning to identify subtypes of survivors that may respond to tailored intervention strategies.

SUMMARY

Several successful critical illness survivor models of care have been implemented and knowledge about effectiveness, cost, and implementation factors of these strategies is growing. Further innovation is needed in intervention development and evaluation to advance the field.

Nutrition in the intensive care unit and early recovery influence functional outcomes for survivors of critical illness: A prospective cohort study

BACKGROUND

Patients who are critically ill may receive suboptimal nutrition that leads to weight loss and increased risk of functional deficits.

METHODS

Our overarching hypothesis is that nutrition in the intensive care unit (ICU) and the early recovery phase associates with functional outcomes at short-term follow-up. We enrolled adult patients who attended the University of Kentucky ICU recovery clinic (ICU-RC) from November 2021 to June 2022. Patients participated in muscle and functional assessments. Nutrition intake and status during the ICU stay were analyzed. The Subjective Global Assessment and a nutrition questionnaire were used to identify changes in intake, ongoing gastrointestinal symptoms, and patient's access to food at the ICU-RC appointment.

RESULTS

Forty-one patients enrolled with a median hospital length of stay (LOS) of 23 days. Patients with 0 days of nil per os (NPO) status throughout hospitalization had a shorter LOS (P = 0.05), were able to complete the five times sit-to-stand test (P = 0.02), and were less likely to experience ICU-acquired weakness (P = 0.04) at short-term follow-up compared with patients with ≥1 day of NPO status. Twenty (48%) patients reported changes in nutrition intake in early recovery compared with before hospitalization. Eight (20%) patients reported symptoms leading to decreased intake and four (10%) reported access to food as a barrier to intake.

CONCLUSION

Barriers to nutrition exist during critical illness and persist after discharge, with almost half of patients reporting a change in intake. Inpatient nutrition intake is associated with functional outcomes and warrants further exploration.

Post-intensive care syndrome and pulmonary fibrosis in patients surviving ARDS-pneumonia of COVID-19 and non-COVID-19 etiologies

The purpose was to examine patient-centered outcomes and the occurrence of lung fibrotic changes on Chest computed tomography (CT) imaging following pneumonia-related acute respiratory distress syndrome (ARDS). We sought to investigate outpatient clinic chest CT imaging in survivors of COVID19-related ARDS and non-COVID-related ARDS, to determine group differences and explore relationships between lung fibrotic changes and functional outcomes. A retrospective practice analysis of electronic health records at an ICU Recovery Clinic in a tertiary academic medical center was performed in adult patients surviving ARDS due to COVID-19 and non-COVID etiologies. Ninety-four patients with mean age 53 ± 13 and 51% male were included (n = 64 COVID-19 and n = 30 non-COVID groups). There were no differences for age, sex, hospital length of stay, ICU length of stay, mechanical ventilation duration, or sequential organ failure assessment (SOFA) scores between the two groups. Fibrotic changes visualized on CT imaging occurred in a higher proportion of COVID-19 survivors (70%) compared to the non-COVID group (43%, p < 0.001). Across both groups, patients with fibrotic changes (n = 58) were older, had a lower BMI, longer hospital and ICU LOS, lower mean RASS scores, longer total duration of supplemental oxygen. While not statistically different, patients with fibrotic changes did have reduced respiratory function, worse performance on the six-minute walk test, and had high occurrences of anxiety, depression, emotional distress, and mild cognitive impairment regardless of initial presenting diagnosis. Patients surviving pneumonia-ARDS are at high risk of impairments in physical, emotional, and cognitive health related to Post-Intensive Care Syndrome. Of clinical importance, pulmonary fibrotic changes on chest CT occurred in a higher proportion in COVID-ARDS group; however, no functional differences were measured in spirometry or physical assessments at ICU follow-up. Whether COVID infection imparts a unique recovery is not evident from these data but suggest that long-term follow up is necessary for all survivors of ARDS.

Multidisciplinary ICU Recovery Clinic Visits: A Qualitative Analysis of Patient-Provider Dialogues

BACKGROUND

Research confirms the heterogeneous nature of patient challenges during recovery from the ICU and supports the need for modifying care experiences, but few data are available to guide clinicians seeking to support patients' individual recovery trajectories.

RESEARCH QUESTION

What is the content of patient-provider dialogues in a telemedicine multidisciplinary ICU recovery clinic (ICU-RC)?

STUDY DESIGN AND METHODS

We conducted a qualitative descriptive study in a telemedicine multidisciplinary ICU-RC at a tertiary academic medical center in the southeastern United States. The sample included 19 patients and 13 caregivers (≥ 18 years of age) attending a telemedicine ICU-RC visit after critical illness resulting from septic shock or ARDS. Patients and caregivers met with an ICU pharmacist, ICU physician, and a psychologist via a secure web-conferencing platform for 33 ICU-RC visits within 12 weeks of hospital discharge. Telemedicine ICU-RC visits were audio-recorded and transcribed verbatim for analysis. A coding system was developed using iterative inductive and deductive approaches.

RESULTS

Two themes were identified from the patient-provider dialogue: (1) problem identification and (2) problem-solving strategies. We identified five subthemes that capture the types of problems identified: health status, mental health and cognition, medication management, health-care access and navigation, and quality of life. Problem-solving subthemes included facilitating care coordination and transitions, providing education, and giving constructive feedback and guidance.

INTERPRETATION

Patients surviving a critical illness experience a complexity of problems that may be addressed best by a multidisciplinary ICU-RC. Through analysis of our telemedicine ICU-RC dialogues, we were able to identify problems and solutions to address challenges during a critical transitional phase of ICU recovery.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03926533; URL: www.

CLINICALTRIALS

gov.

Factors Influencing Engagement with in-Person Intensive Care Unit Recovery Clinic Services

Background: Intensive Care Unit recovery clinics (ICU-RC), are multidisciplinary outpatient clinics designed to identify and treat post-intensive care syndrome impairments unique to each survivor of critical illness. Engagement is limited, thus we aimed to describe patient- and hospitalization-related sociodemographic factors associated with scheduling and attending in-person ICU-RC visits. Design: Consecutive case series of prospectively collected ICU-RC referral data. Setting: Data was collected over a 9-year period (2012-2020) for patients referred to an ICU-RC from ICUs at an academic medical center in the southeast United States. Participants: 251 adults admitted to a medical, surgical, burn, or trauma ICU referred to the ICU-RC and eligible to be scheduled for a visit. Main Outcome and Measures: The main study outcome was scheduling and completing an ICU-RC visit. Independent variables included patient demographics, ICU visit characteristics (eg, diagnosis, ventilator days), severity of illness, discharge disposition, ICU-RC referral criteria (eg, shock, delirium), and clinic scheduling administrative data (eg, referral date, clinic visit date). Results: Of 251 ICU-RC referrals eligible for a visit, 128 were scheduled, and 91 completed a visit. In univariate models older age, unspecified shock, and distance from the clinic location were associated with decreased in-person ICU-RC engagement. In a multivariable logistic regression using the same predictors and interactions, older age, unspecified shock, and home-to-clinic distance remained as factors decreasing the likelihood of ICU-RC engagement. There was a decreasing likelihood of scheduling and attending an ICU-RC visit for every additional mile of distance the patient lived from the ICU-RC. Male sex was a strong predictor of completing an ICU-RC visit. Conclusions: Older ICU survivors and those who live farther from the clinic site are less likely to engage in an in-person ICU-RC. Innovation and telemedicine strategies are needed to improve access to ICU recovery care for these populations.

Effects of COVID-19 Acute Respiratory Distress Syndrome Intensive Care Unit Survivor Telemedicine Clinic on Patient Readmission, Pain Perception, and Self-Assessed Health Scores: Randomized, Prospective, Single-Center, Exploratory Study

BACKGROUND

Post-intensive care syndrome (PICS) affects up to 50% of intensive care unit (ICU) survivors, leading to long-term neurocognitive, psychosocial, and physical impairments. Approximately 80% of COVID-19 pneumonia ICU patients are at elevated risk for developing acute respiratory distress syndrome (ARDS). Survivors of COVID-19 ARDS are at high risk of unanticipated health care utilization postdischarge. This patient group commonly has increased readmission rates, long-term decreased mobility, and poorer outcomes. Most multidisciplinary post-ICU clinics for ICU survivors are in large urban academic medical centers providing in-person consultation. Data are lacking on the feasibility of providing telemedicine post-ICU care for COVID-19 ARDS survivors.

OBJECTIVE

We explored the feasibility of instituting a COVID-19 ARDS ICU survivor telemedicine clinic and examined its effect on health care utilization post-hospital discharge.

METHODS

This randomized, unblinded, single-center, parallel-group, exploratory study was conducted at a rural, academic medical center. Study group (SG) participants underwent a telemedicine visit within 14 days of discharge, during which a 6-minute walk test (6MWT), EuroQoL 5-Dimension (EQ-5D) questionnaire, and vital signs logs were reviewed by an intensivist. Additional appointments were arranged as needed based on the outcome of this review and tests. The control group (CG) underwent a telemedicine visit within 6 weeks of discharge and completed the EQ-5D questionnaire; additional care was provided as needed based on findings in this telemedicine visit.

RESULTS

Both SG (n=20) and CG (n=20) participants had similar baseline characteristics and dropout rate (10%). Among SG participants, 72% (13/18) agreed to pulmonary clinic follow-up, compared with 50% (9/18) of CG participants (P=.31). Unanticipated visits to the emergency department occurred for 11% (2/18) of the SG compared with 6% (1/18) of the CG (>.99). The rate of pain or discomfort was 67% (12/18) in the SG compared with 61% (11/18) in the CG (P=.72). The anxiety or depression rate was 72% (13/18) in the SG versus 61% (11/18; P=.59) in the CG. Participants' mean self-assessed health rating scores were 73.9 (SD 16.1) in the SG compared with 70.6 (SD 20.9) in the CG (P=.59). Both primary care physicians (PCPs) and participants in the SG perceived the telemedicine clinic as a favorable model for postdischarge critical illness follow-up in an open-ended questionnaire regarding care.

CONCLUSIONS

This exploratory study found no statistically significant results in reducing health care utilization postdischarge and health-related quality of life. However, PCPs and patients perceived telemedicine as a feasible and favorable model for postdischarge care among COVID-19 ICU survivors to facilitate expedited subspecialty assessment, decrease unanticipated postdischarge health care utilization, and reduce PICS. Further investigation is warranted to determine the feasibility of incorporating telemedicine-based post-hospitalization follow-up for all medical ICU survivors that may show improvement in health care utilization in a larger population.

Evolution in Care Delivery within Critical Illness Recovery Programs during the COVID-19 Pandemic: A Qualitative Study

Rationale: There are limited data on the impact of the coronavirus disease (COVID-19) pandemic on intensive care unit (ICU) recovery clinic care delivery practices. Objectives: We sought to better understand the patient-level factors affecting ICU recovery clinic care and changing clinical thinking during the COVID-19 pandemic. We also sought to understand how the COVID-19 pandemic sparked innovation within ICU recovery clinics. Methods: A multicenter qualitative study was conducted with ICU recovery clinic interprofessional clinicians involved with the Critical and Acute Illness Recovery Organization (CAIRO) between February and March 2021. Data were collected using semistructured interviews and were analyzed using thematic analysis. Key themes were organized in a working analytical framework. Results: Twenty-nine participants from 15 international sites participated in the study. Participants identified three patient-level key themes that influenced care delivery in ICU recovery programs: 1) social isolation, 2) decreased emotional reserve in patients and families, and 3) substantial social care needs. Changes in ICU recovery clinic care delivery occurred at both the clinician level (e.g., growing awareness of healthcare disparities and inequities, recognition of financial effects of illness, refinement of communication skills, increased focus on reconstructing the illness narrative) and the practice level (e.g., expansion of care delivery modes, efforts to integrate social care) in response to each of the patient-level themes. Identified gaps in ICU recovery clinic care delivery during the COVID-19 pandemic included a need for multidisciplinary team members, access to care issues (e.g., digital poverty, health insurance coverage, language barriers), and altered family engagement. Conclusions: This study demonstrates that addressing patient-level factors such as efforts to integrate social care, address financial needs, refine provider communication skills (e.g., empathic listening), and enhance focus on reconstructing the illness narrative became important priorities during the ICU recovery clinic visit during the COVID-19 pandemic. We also identified several ongoing gaps in ICU recovery clinic care delivery that highlight the need for interventions focused on the integration of social and clinic services for critical care survivors.

Post-intensive care syndrome: A review for the primary care NP

ABSTRACT

Post-intensive care syndrome is a costly and complicated collection of physical, cognitive, and mental health problems experienced by survivors of critical illness. The primary care NP is uniquely positioned to assess, monitor, manage, and treat patients with this syndrome following hospital discharge.

Establishing a Cardiac ICU Recovery Clinic: Characterizing a Model for Continuity of Cardiac Critical Care

BACKGROUND

Care in the cardiovascular intensive care unit (CICU) has become increasingly intricate due to a temporal rise in noncardiac diagnoses and overall clinical complexity with high risk for short-term rehospitalization and mortality. Survivors of critical illness are often faced with debility and limitations extending beyond the index hospitalization. Comprehensive ICU recovery programs have demonstrated some efficacy but have primarily targeted survivors of acute respiratory distress syndrome or sepsis. The efficacy of dedicated ICU recovery programs on the CICU population is not defined.

METHODS

We aim to describe the design and initial experience of a novel CICU-recovery clinic (CICURC). The primary outcome was death or rehospitalization in the first 30 days following hospital discharge. Self-reported outcome measures were performed to assess symptom burden and independence in activities of daily living.

RESULTS

Using standardized criteria, 41 patients were referred to CICURC of which 78.1% established care and were followed for a median of 88 (56-122) days. On intake, patients reported a high burden of heart failure symptoms (KCCQ overall summary score 29.8 [18.0-47.5]), and nearly half (46.4%) were dependent on caretakers for activities of daily living. Thirty days postdischarge, no deaths were observed and the rate of rehospitalization for any cause was 12.2%.

CONCLUSIONS

CICU survivors are faced with significant residual symptom burden, dependence upon caretakers, and impairments in mental health. Dedicated CICURCs may help prioritize treatment of ICU related illness, reduce symptom burden, and improve outcomes. Interventions delivered in ICU recovery clinic for patients surviving the CICU warrant further investigation.

Meeting the Challenges of Establishing Intensive Care Unit Follow-up Clinics

Intensive care unit follow-up clinics are becoming an increasingly widespread intervention to facilitate the physical, cognitive, psychiatric, and social rehabilitation of survivors of critical illness who have post-intensive care syndrome. Developing and sustaining intensive care unit follow-up clinics can pose significant challenges, and clinics need to be tailored to the physical, personnel, and financial resources available at a given institution. Although no standard recipe guarantees a successful intensive care unit aftercare program, emerging clinics will need to address a common set of hurdles, including securing an adequate space; assembling an invested, multidisciplinary staff; procuring the necessary financial, information technology, and physical stuff; using the proper screening tools to identify patients most likely to benefit and to accurately identify disabilities during the visit; and selling it to colleagues, hospital administrators, and the community at large.

Acute kidney injury contributes to worse physical and quality of life outcomes in survivors of critical illness

Objectives

Survivors of critical illness and acute kidney injury (AKI) are at risk of increased morbidity. The purpose of this study was to compare physical, emotional, and cognitive health in survivors of critical illness with and without AKI.

Methods

Retrospective cohort study of adult (≥ 18 years old) survivors of critical illness due to sepsis and/or acute respiratory failure who attended follow-up in a specialized ICU Recovery Clinic. Outcomes were evaluated during 3-month visit and comprised validated tests for evaluation of physical function, muscle strength, cognitive and emotional health, and self-reported health-related quality of life (HRQOL). Descriptive statistics and group comparisons were performed.

Results

A total of 104 patients with median age of 55 [49-64] years, 54% male, and median SOFA score of 10 [8-12] were analyzed. Incidence of AKI during ICU admission was 61 and 19.2% of patients required renal replacement therapy (RRT). Patients with AKI stage 2 or 3 (vs. those with AKI stage 1 or no AKI) walked less on the 6-min walk test (223 ± 132 vs. 295 ± 153 m, p = 0.059) and achieved lower of the predicted walk distance (38% vs. 58%, p = 0.041). Similar patterns of worse physical function and more significant muscle weakness were observed in multiple tests, with overall worse metrics in patients that required RRT. Patients with AKI stage 2 or 3 also reported lower HRQOL scores when compared to their counterparts, including less ability to return to work or hobby, or reengage in driving. There were no significant differences in cognitive function or emotional health between groups.

Conclusions

Survivors of critical illness and AKI stage 2 or 3 have increased physical debility and overall lower quality of life, with more impairment in return to work, hobby, and driving when compared to their counterparts without AKI or AKI stage 1 at 3 months post-discharge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02749-z.

Characteristics of Post-ICU and Post-COVID Recovery Clinics in 29 U.S. Health Systems

The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States.

Patients Surviving Critical COVID-19 have Impairments in Dual-task Performance Related to Post-intensive Care Syndrome

Objective

The purpose was to examine Dual Task (DT) performance in patients surviving severe and critical COVID-19 compared to patients with chronic lung disease (CLD). Secondarily, we aimed to determine the psychometric properties of the Timed Up and Go (TUG) test in patients surviving COVID-19.

Design

Prospective, cross-sectional, observational study.

Setting

Academic medical center within United States.

Patients

Ninety-two patients including 36 survivors of critical COVID-19 that required mechanical ventilation (critical-COVID), 20 patients recovering from COVID-19 that required supplemental oxygen with hospitalization (severe-COVID), and 36 patients with CLD serving as a control group.

Measurements and Main Results

Patients completed the TUG, DT-TUG, Short Physical Performance Battery (SPPB), and Six Minute Walk Test (6MWT) 1-month after hospital discharge. A subset of patients returned at 3-months and repeated testing to determine the minimal detectable change (MDC). Critical-COVID group (16.8 ± 7.3) performed the DT-TUG in significantly slower than CLD group (13.9 ± 4.8 s; P = .024) and Severe-COVID group (13.1 ± 5.1 s; P = .025). Within-subject difference between TUG and DT-TUG was also significantly worse in critical-COVID group (−21%) compared to CLD (−10%; P = .012), even despite CLD patients having a higher comorbid burden (P < .003) and older age (P < .001). TUG and DT-TUG demonstrated strong to excellent construct validity to the chair rise test, gait speed, and 6MWT for both COVID-19 groups (r = −0.84to 0.73, P < .05). One- and 3-months after hospital discharge there was a floor effect of 14% (n = 5/36) and 5.2% (n = 1/19), respectively for patients in the critical-COVID group. Ceiling effects were noted in four (11%) critical-COVID, six (30%) severe-COVID patients for the TUG and DT-TUG at 1-month.

Conclusion

The ability to maintain mobility performance in the presence of a cognitive DT is grossly impaired in patients surviving critical COVID-19. DT performance may subserve the understanding of impairments related to Post-intensive care syndrome (PICS) for survivors of critical illness.

COVID-19 pandemic: the impact on Canada’s intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity.

The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces.

Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions.

This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided.

Respiratory Therapists in an ICU Recovery Clinic: Two Institutional Experiences and Review of the Literature

Post-intensive care syndrome is an increasingly recognized complication of critical illness, with patients reporting new problems in physical, mental health and/or psychosocial, and cognitive function for months to years after their acute illness. As a way of diagnosing and treating post-intensive care syndrome, many centers around the world have established ICU recovery clinics, which take a multidisciplinary approach to care after the ICU. Dyspnea and pulmonary dysfunction are frequently encountered concerns in the post-ICU population. Despite this, few ICU recovery clinics have described how respiratory therapists (RTs) can contribute to treating these symptoms. We reviewed the literature with regard to the roles of an RT in post-ICU follow-up, described our institutional experiences with having RTs as part of our ICU recovery clinics, and identified additional ways that RTs might contribute to a post-intensive care syndrome diagnosis and treatment. Although RTs can provide invaluable experience and contributions to an ICU recovery clinic, there are few articles in the published literature on the ways in which this can be accomplished. We, therefore, provide analogies to other multidisciplinary clinic models as well as our own experiences. Future studies should focus on examining the impact of respiratory therapy diagnostic testing and interventions in the ICU recovery clinic on both patient and provider outcomes.

Transitions from short to long-term outcomes in pediatric critical care: considerations for clinical practice

Most children are surviving critical illness in highly resourced pediatric intensive care units (PICUs). However, in research studies, many of these children survive with multi-domain health sequelae that has the potential to affect development over many years, termed post-intensive care syndrome-pediatrics (PICS-p). Clinically, there are no recommendations for the assessment and follow-up of children with critical illness as exists for the premature neonatal and congenital heart disease populations. In research studies, primary and secondary outcomes are largely assessed at or prior to hospital discharge, disregarding post-hospital outcomes important to PICU stakeholders. Incorporating longer term outcomes into clinical and research programs, however, can no longer be overlooked. Barriers to outcomes assessments are varied and generalized vs. individualized, but some PICU centers are discovering how to overcome them and are providing this service to families-sometimes specific populations-in need. Research programs and funders are increasingly recognizing the value and need to assess long-term outcomes post-PICU. Finally, we should seek the strong backing of the PICU community and families to insist that long-term outcomes become our new clinical standard of care. PICUs should consider development of a multicenter, multinational collaborative to assess clinical outcomes and optimize care delivery and patient and family outcomes. The aim of this review is to present the potential considerations of implementing long-term clinical follow-up following pediatric critical illness.

Safety and Feasibility of an Interdisciplinary Treatment Approach to Optimize Recovery From Critical Coronavirus Disease 2019

Supplemental Digital Content is available in the text.

OBJECTIVES:

Examine the safety and feasibility of a multimodal in-person or telehealth treatment program, administered in acute recovery phase for patients surviving critical coronavirus disease 2019.

DESIGN:

Pragmatic, pre-post, nonrandomized controlled trial with patients electing enrollment into one of the two recovery pathways.

SETTING:

ICU Recovery Clinic in an academic medical center.

PATIENTS:

Adult patients surviving acute respiratory failure due to critical coronavirus disease 2019.

INTERVENTIONS:

Patients participated in combined ICU Recovery clinic and 8 weeks of physical rehabilitation delivered: 1) in-person or 2) telehealth. Patients received medical care by an ICU Recovery Clinic interdisciplinary team and physical rehabilitation focused on aerobic, resistance, and respiratory muscle training.

MEASUREMENTS AND MAIN RESULTS:

Thirty-two patients enrolled with mean age 57 ± 12, 62% were male, and the median Sequential Organ Failure Assessment score was 9.5. There were no differences between the two groups except patients in telehealth pathway (n = 10) lived further from clinic than face-to-face patients (162 ± 60 vs 31 ± 47 kilometers, t = 6.06, p < 0.001). Four safety events occurred: one minor adverse event in the telehealth group, two minor adverse events, and one major adverse event in the in-person group. Three patients did not complete the study (two in-person and one telehealth). Six-minute walk distance increased to 101 ± 91 meters from pre to post (n = 29, t = 6.93, p < 0.0001), which was similar between the two groups (110 vs 80 meters, t = 1.34, p = 0.19). Self-reported levels of anxiety, depression, and distress were high in both groups with similar self-report quality of life.

CONCLUSIONS:

A multimodal treatment program combining care from an interdisciplinary team in an ICU Recovery Clinic with physical rehabilitation is safe and feasible in patients surviving the ICU for coronavirus disease 2019 acute respiratory failure.

Physical Therapy Management of an Individual With Post-COVID Syndrome: A Case Report

OBJECTIVE

The purpose of this case report is to provide the clinical presentation and physical therapist management for a patient with post-COVID syndrome. Secondarily, the report highlights the importance of assessing cognitive and emotional health in patients with post-COVID syndrome.

METHODS (CASE DESCRIPTION)

A 37-year-old woman tested positive for SARS-CoV-2 and developed mild COVID-19 disease but did not require supplemental oxygen or hospitalization. The patient experienced persistent symptoms, including dyspnea, headaches, and cognitive fog. On day 62, they participated in an outpatient physical therapist evaluation that revealed deficits in exercise capacity, obtaining 50% of their age-predicted 6-minute walk distance. They had minor reductions in muscle strength and cognitive function. Self-reported quality of life was 50, and they scored above established cut-off scores for provisional diagnosis of posttraumatic stress disorder (PTSD).

RESULTS

The patient participated in biweekly physical therapist sessions for 8 weeks, which included aerobic training, strengthening exercises, diaphragmatic breathing techniques, and mindfulness training. Metabolic equivalent for task levels increased with variability over the course of the program. The patient's muscle strength, physical function, and exercise capacity improved. 6-Minute walk distance increased by 199 m, equating to 80% of their age-predicted distance. Quality of life and PTSD scores did not improve. At evaluation after physical therapy, the patient was still experiencing migraines, dyspnea, fatigue, and cognitive dysfunction.

CONCLUSION

This case report described the clinical presentation and physical therapist management of a person with post-COVID syndrome, a novel health condition for which little evidence exists to guide rehabilitation examination and interventions. Physical therapists should consider cognitive function and emotional health in their plan of care for patients with post-COVID syndromes.

IMPACT

This case alerts physical therapists to post-COVID syndrome-which can include debilitating symptoms of decreased aerobic tolerance, anxiety, PTSD, and cognitive dysfunction-and to the role that therapists can play in assessing these symptoms and managing these patients.

Acute skeletal muscle wasting and dysfunction predict physical disability at hospital discharge in patients with critical illness

BACKGROUND

Patients surviving critical illness develop muscle weakness and impairments in physical function; however, the relationship between early skeletal muscle alterations and physical function at hospital discharge remains unclear. The primary purpose of this study was to determine whether changes in muscle size, strength and power assessed in the intensive care unit (ICU) predict physical function at hospital discharge.

METHODS

Study design is a single-center, prospective, observational study in patients admitted to the medicine or cardiothoracic ICU with diagnosis of sepsis or acute respiratory failure. Rectus femoris (RF) and tibialis anterior (TA) muscle ultrasound images were obtained day one of ICU admission, repeated serially and assessed for muscle cross-sectional area (CSA), layer thickness (mT) and echointensity (EI). Muscle strength, as measured by Medical Research Council-sum score, and muscle power (lower-extremity leg press) were assessed prior to ICU discharge. Physical function was assessed with performance on 5-times sit-to-stand (5STS) at hospital discharge.

RESULTS

Forty-one patients with median age of 61 years (IQR 55-68), 56% male and sequential organ failure assessment score of 8.1 ± 4.8 were enrolled. RF muscle CSA decreased significantly a median percent change of 18.5% from day 1 to 7 (F = 26.6, p = 0.0253). RF EI increased at a mean percent change of 10.5 ± 21% in the first 7 days (F = 3.28, p = 0.081). At hospital discharge 25.7% of patients (9/35) met criteria for ICU-acquired weakness. Change in RF EI in first 7 days of ICU admission and muscle power measured prior to ICU were strong predictors of ICU-AW at hospital discharge (AUC = 0.912). Muscle power at ICU discharge, age and ICU length of stay were predictive of performance on 5STS at hospital discharge.

CONCLUSION

ICU-assessed muscle alterations, specifically RF EI and muscle power, are predictors of diagnosis of ICU-AW and physical function assessed by 5x-STS at hospital discharge in patients surviving critical illness.