It Takes a Team - Contributions of Each Team Member in a Post-Intensive Care Syndrome Clinic Model

2015 - 4 August – Post-Intensive Care Syndrome
Joanna L. Stollings, PharmD, BCPS; Elizabeth L. Huggins, AG-ACNP; James C. Jackson, PsyD; Carla M. Sevin, MD
Four experts delineate the dynamics of their multiprofessional care team as a potential model for ICU follow-up care.

 

Advancements in critical care have decreased mortality and resulted in an increased probability of living through even the most serious illnesses.(1-3) The Society of Critical Care Medicine has recently termed the combination of physical deficits such as impaired pulmonary function and neuromuscular weakness, neurologic and psychological morbidities such as cognitive dysfunction and posttraumatic stress disorder (PTSD), and overall poor health-related quality of life as post-intensive care syndrome (PICS).(4,5) Survivors with PICS are frequently trapped in a cycle of recurrent illness and rehospitalization after being in the intensive care unit (ICU) and have increased mortality.(6) Few reach their goal of full recovery.(7-11) The establishment of an ICU follow-up clinic has been proposed as one way to minimize and manage long-term complications for these patients. The goals of a PICS clinic include optimization of cognitive, physical, and psychological function following critical illness, improved care coordination, and decreased healthcare utilization.

There is no one consistent model of a PICS clinic. Nurse-led clinics have been in evidence in Europe since the 1990s. However, this has not been a consistent model of care in the United States. In 2012, The ICU Recovery Center at Vanderbilt was established to explore the feasibility and effectiveness of an ICU follow-up program and represents one potential model of ICU follow-up. Our team consists of an acute care nurse practitioner, a critical care pharmacist, a neuropsychologist, a pulmonary critical care physician, and a case manager. The role of these providers within the clinic is unique in that it combines the perspectives of both inpatient and outpatient practitioners and attempts to bridge the gap between intensive care and the outpatient setting, with the ultimate goal of full recovery for patients and their families. The elements of our program were initially established based on the problems we were seeing in survivors of critical illness and the concerns that these survivors and their families reported to us. These elements have been refined over the past three years and are described below:

 

1. A formal medical examination is provided during the visit. First, spirometry and six-minute walk testing are performed to screen for respiratory and airway sequelae, as well as persistent critical illness myopathy. A structured interview is then conducted by a critical care nurse practitioner to review the patient’s hospital course and any current physical complaints or problems. The physical examination is focused on sequelae related to critical illness, including but not limited to tracheostomy, respiratory failure, indwelling vascular catheters, weakness, and skin breakdown.

2. The pharmacist completes a thorough medication reconciliation, drug therapy review, evaluation of side effects, patient counseling, and promotion of medication adherence. Barriers to medication adherence, including cost and lack of assistance tools, are then targeted, with the goal of  improving adherence and minimizing adverse medication-related events.

 

3. A cognitive and mental health evaluation is performed by a neuropsychologist to screen for problems common in ICU survivors, including cognitive dysfunction, depression, and PTSD. Global cognitive functioning, executive functioning and attention are evaluated with the assistance of several widely available instruments, including the Montreal Cognitive Assessment (MoCA)(12) and the Trail Making Test (TMT) Parts A and B.(13) Depression is assessed with the Hospital Anxiety and Depression Scale (HADS)(14) or the Beck Depression Inventory®-II (BDI®-II),(15) and PTSD screening is done with the Posttraumatic Stress Disorder Checklist (PCL).(16) Findings from this brief screening are used in a patient-centered assessment, with the results and implications explained to the patient, at which time patient feedback is solicited.(17)

4. Case management has been shown to positively impact diverse outcomes, including hospital readmission rates and disease management.(18,19) A brief case management consultation is conducted to screen for missing services and to link the patient to relevant resources, including community mental health and fitness. A case manager is often needed to arrange home care and durable medical equipment. Further, a case manager can review how to access resources such as after-hours clinics and express care that may save the patient a trip to the emergency department and potentially prevent readmission. If the patient does not have a primary care provider, a case manager can assist the patient in establishing a relationship with such a provider.
 

A final consultation with patients and their families, wherein an intensivist summarizes the hospital course, physiologic testing performed during the visit, and any problems identified, is a useful conclusion to this interdisciplinary visit. New and persistent diagnoses, the treatment plan, additional specialist referrals, and medication changes are reviewed. Patients and family members are given the opportunity to ask questions. A survivorship care plan (SCP), based on those used in the cancer survivorship arena but tailored to address the unique needs of patients after critical illness, is also shared with the patient at this time. The SCP includes contact information for the care team, basic historic health information, detailed information about the patient’s critical illness course, a list of medications, and specific recommendations for follow-up care with timelines. Often, the period after critical care is a teachable moment in which the patient is open to significant lifestyle changes that have the potential to improve health and maintain recovery, such as smoking cessation or preventative immunization, and these are addressed in our model by a physician familiar with the patient’s critical care course. 
 

Other attempts to improve the post-ICU period have included additional disciplines such as physical therapy, occupational therapy, and palliative care. The team members required may vary based on the healthcare setting and the resources available.
 

As the number of patients admitted to ICUs and surviving increases, the importance of recognizing and treating PICS grows as well.4,6 Although its effectiveness is yet to be proven, an interdisciplinary PICS clinic is a logical, feasible way to treat this syndrome. Each member of the PICS team plays an integral role in providing care to patients and family members. Further research is needed to evaluate the impact of PICS clinics on outcomes for ICU survivors and their families.

References

1. Iwashyna TJ, Cooke CR, Wunsch H, Kahn JM.  Population burden of long-term survivorship after severe sepsis in older Americans.  J Am Geriatr Soc. 2012 Jun;60(6):1070-1077. doi: 10.1111/j.1532-5415.2012.03989.x.
2. Kaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R.  Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000-2012.  JAMA. 2014 Apr 2;311(13):1308-16. doi: 10.1001/jama.2014.2637.
3. Zambon M, Vincent JL.  Mortality rates for patients with acute lung injury/ARDS have decreased over time.  Chest. 2008 May;133(5):1120-1127. doi: 10.1378/chest.07-2134.
4. Iwashyna TJ.  Survivorship will be the defining challenge of critical care in the 21st century.  Ann Intern Med. 2010 Aug 3;153(3):204-205. doi: 10.7326/0003-4819-153-3-201008030-00013.
5. Needham DM, Davidson J, Cohen H, et al.  Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.  Crit Care Med. 2012 Feb;40(2):502-509. doi: 10.1097/CCM.0b013e318232da75.
6. Unroe M, Kahn JM, Carson SS, et al.  One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study.  Ann Intern Med. 2010 Aug 3;153(3):167-175. doi: 10.7326/0003-4819-153-3-201008030-00007.
7. Herridge MS, Cheung AM, Tansey CM, et al.  One-year outcomes in survivors of the acute respiratory distress syndrome.  N Engl J Med. 2003 Feb 20;348(8):683-693.
8. Jackson JC, Hart RP, Gordon SM, et al.  Six-month neuropsychological outcome of medical intensive care unit patients.  Crit Care Med. 2003 Apr;31(4):1226-1234.
9. Iwashyna TJ, Ely EW, Smith DM, Langa KM.  Long-term cognitive impairment and functional disability among survivors of severe sepsis.  JAMA. 2010 Oct 27;304(16):1787-1794. doi: 10.1001/jama.2010.1553.
10. Davydow DS, Hough CL, Langa KM, Iwashyna TJ.  Symptoms of depression in survivors of severe sepsis: a prospective cohort study of older Americans.  Am J Geriatr Psychiatry. 2013 Sep;21(9):887-897. doi: 10.1016/j.jagp.2013.01.017.
11. Wunsch H, Christiansen CF, Johansen MB, et al.  Psychiatric diagnoses and psychoactive medication use among nonsurgical critically ill patients receiving mechanical ventilation.  JAMA. 2014 Mar 19;311(11):1133-1142. doi: 10.1001/jama.2014.2137.
12.  Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment (MoCA): a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695-699.
13. Reitan RM.  Validity of the Trail Making test as an indicator of organic brain damage. Percept. Mot Skills. 1958;8:271-276.
14. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–370.
15. Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation; 1996.
16. Blanchard EB, Jones-Alexander J, Buckley TC,  Forneris CA. Psychometric properties of the PTSD checklist (PCL). Behav Res Ther. 1996;34:669-673.
17. Gorske TT. Therapeutic neuropsychological assessment: a humanistic model and case example. J Humanistic Psychol. 2008;48.3:320-339.
18. Prescott HC, Langa KM, Liu V, Escobar GJ, Iwashyna TJ.  Increased 1-year healthcare use in survivors of severe sepsis.  Am J Respir Crit Care Med. 2014 Jul 1;190(1):62-69. doi: 10.1164/rccm.201403-0471OC.
19.  Prescott HC, Langa KM, Iwashyna TJ.   Readmission diagnoses after hospitalization for severe sepsis and other acute medical conditions.  JAMA. 2015 Mar 10;313(10):1055-1057. doi: 10.1001/jama.2015.1410.