Data indicate that more than 6 million people will become critically ill each year, and of these patients, an increasing number will survive due to advances in critical care. These treatments, however, can come at a premium cost. As the long-term effects of critical illness become more well-known, the need to design and implement effective interventions to rescue critical illness survivors from incomplete recovery has become a pressing need for many clinicians. Yet, evidence-based guidelines for ICU follow-up and recovery are lacking.
Addressing the Need
To help address this need, Carla M. Sevin, MD, and colleagues sought to describe the design and initial implementation of an ICU Recovery Center (ICU-RC). “We started the ICU-RC at Vanderbilt University School of Medicine in 2012 to meet what appeared to be an unmet need related to ICU aftercare and recovery services,” says Dr. Sevin. “Many investigations had documented the presence of significant and entrenched problems in ICU survivors—problems in areas of physical, emotional, and cognitive functioning, among others. These issues had not been a point of focus for intensivists, who are trained to attend to acute and critical concerns when patients are in the ICU and are less oriented to the needs of patients after the ICU.”
Dr. Sevin adds that the study was important because there was no accepted model of care to see patients after an ICU stay, with “no way for our patients or their families to access critical care specialists after they left the hospital and little feedback about the long-term success of critical care.”
For their study published in the Journal of Critical Care, Dr. Sevin and her research team used clinical criteria to develop the ICU-RC, identify patients at high risk for post intensive care syndrome (PICS), and offer them post-ICU care.
Among the patients observed, 71% survived to hospital discharge; 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. Of previously working patients, only 15% had returned to work.
“New impairments are common in ICU survivors and affect even young and previously healthy patients,” says Dr. Sevin. “Those who are vigorous and robust at baseline are not immune. The current model of care for these patients, which is often to follow up with their primary care provider, is inadequate. Many of our patients do not have a preexisting relationship with a family doctor, and those who do are not benefiting from good communication between the ICU and their primary care physician. Most patients who are sick enough to need our services will have many transitions of care before they get back home.”
Interpreting the Data
Study participants were a pragmatic clinical population, notes Dr. Sevin. “Thus, those who attended clinic had the resources to do so,” she says. “In many cases, this meant a family member or caregiver to remember the appointment and drive them there, insurance or other financial resources, and the insight to see that some of their problems were things we could help them with. Patients who were admitted to the ICU with respiratory failure were more likely to attend clinic, for example (Table). This could mean they had more noticeable impairments they felt needed to be addressed or that this population represents ‘the healthiest of the sickest,’ meaning we could be missing patients with even more severe impairments who are not able to attend in person. This hypothesis is further bolstered by the fact that patients who went anywhere more intensive than inpatient rehabilitation—for example, a long-term acute care facility or skilled nursing facility—may not have ever been well enough to be discharged to home, much less come to clinic. This area needs further research and may provide important prognostic information for us as intensivists as we care for patients in the ICU.”
Dr. Sevin notes that, while preliminary, the study findings underscore gaps in knowledge about ICU recovery. “Patients who will benefit from ICU aftercare may be select,” she says, “and we don’t know exactly which patients need care, or what we should be providing. It seems likely that we need to broaden our vision of the critical care arc. The care we provide in the ICU has long-term implications, and we owe it to our patients and families, with whom we have worked so intensively in the ICU, to design systems to ensure their best possible recovery.”