Models for a Post-Intensive Care Syndrome Clinic - Targeted Goals and Barriers

2015 - 4 August – Post-Intensive Care Syndrome
Elizabeth L. Huggins, AG-ACNP; Joanna L. Stollings, PharmD, BCPS; James C. Jackson, PsyD; Carla M. Sevin, MD
Experts discuss the purpose and currently in practice model of PICS clinics.
 
Advances in technology and medicine have reduced mortality rates and extended the lives of thousands of critically ill patients. These advances have shifted the concern from survival to quality of life and preservation of function, including cognitive functioning, mental health functioning and physical functioning. As others have observed, the metabolic derangements and perturbations associated with critical illness and intensive care unit (ICU) hospitalization often cast a long shadow; preliminary data suggest that the sequelae of critical illness represent a significant public health concern.(1) For example, evidence suggests that more than half of ICU survivors have cognitive impairment,(2) approximately a third have depression,(3) and up to 20% have posttraumatic stress disorder.(4) Physical debility is also common.(5) Collectively, the constellation of problems experienced by ICU survivors is referred to as post-intensive care syndrome (PICS). Methods of preventing the development of this condition have yet to be identified.(6) One promising approach involves evaluation of patients in PICS clinics, particularly in the early post-discharge period.
 
Although PICS was not an existing clinical entity at the time, the development of clinics to address patients’ challenges after intensive care treatment began in the United Kingdom more than 20 years ago.(7) (The first clinic was in Reading, United Kingdom, in 1993.) During the past 15 years, many more clinics have emerged across the United Kingdom and Australia. More than half of them are run by nurses, and most of them treat only patients who had ICU stays of more than three days. Roughly one-third of these clinics have access to psychology and physical therapy services for their patients.(8) Although effectiveness data are lacking, patient satisfaction with this model of care has been high.(9-11)
 
Building on the success of follow-up clinics in the United Kingdom, the first PICS clinic in the United States was established in 2011 by the pulmonary/critical care and geriatrics divisions at the Indiana University School of Medicine. The Critical Care Recovery Center (CCRC) focused on delivering collaborative care to ICU survivors, specifically targeting geriatric patients with depression and psychological disorders.(12) Its goals were similar to those of the European clinics: improve patient outcomes after ICU discharge, address PICS using a multidisciplinary team, decrease readmission rates and morbidities, and improve the quality of life for patients after critical illness. Patient recruitment was focused on adult patients who had spent more than 48 hours on mechanical ventilation or had had delirium for more than 48 hours. The CCRC was designed to have two assessment phases and then follow-up visits, with a staff that included registered nurses, social workers and physicians.(12)
 
In 2012, Vanderbilt University opened the second PICS clinic in the United States, The ICU Recovery Center. Much like the CCRC, the Vanderbilt PICS clinic takes a multidisciplinary approach to improving the long-term outcomes of patients after ICU discharge. These outcomes include pulmonary functioning, overall physical health, cognitive functioning and mental health, medication safety and reconciliation, and the degree of return to basic daily function. Patients referred to the clinic are recruited from all adult ICUs and are screened and tracked by the clinic team during hospitalization. Eligible patients include adults with severe acute respiratory distress syndrome, sepsis, delirium, and those requiring mechanical ventilation.
Although many of our observations to date are anecdotal, we have found that it is most beneficial for patients to be evaluated in the clinic after they have been home for two to four weeks. The clinic is staffed by a critical care pulmonologist, a clinical pharmacist, a neuropsychologist, an acute care nurse practitioner, and a nurse case manager. The clinic visit lasts one to two hours and includes pulmonary function tests, a six-minute walk test, a full history and physical examination, a medication review, a neurocognitive examination, and a meeting with a case manager. The clinic visit provides an opportunity to identify the ongoing needs of the patient and frequently results in referrals for physical therapy and medical subspecialty clinics, as well as discussions about work re-entry or end-of-life care, among other topics. At the conclusion of each clinic visit, the team discusses each aspect of the patient’s recovery and prepares a letter summarizing its findings and recommendations for the patient’s primary care provider.
 
Both the CCRC and the Vanderbilt PICS clinic have sought to improve long-term outcomes, decrease hospital readmission rates and decrease morbidity associated with PICS; however, there continue to be barriers to effective post-ICU care. In our experience, two prominent obstacles are the availability of adequate resources and the logistic challenges of recruiting patients. For a PICS clinic to identify and treat the problems associated with critical illness, basic resources are required, such as pulmonary function testing, laboratory capabilities, and a complement of multidisciplinary providers.
 
The process of recruiting patients who may benefit from a PICS clinic and tracking them through an often long and complicated hospital stay is time consuming. Patients are frequently transferred from the ICU to a step-down unit, where they may stay for weeks before being discharged to a rehabilitation facility and ultimately going home. Recruitment is also challenging at times because some patients feel overwhelmed by the number of providers they have (or simply do not want to travel back to the hospital) and are thus lost in follow-up. Many of these barriers can be addressed with additional funds, resources and personnel. The recruitment process can be improved and streamlined with both a local champion (usually a physician leader who actively advocates for participation in the clinic) and a dedicated staff member who is able to recruit, track and refer patients on a daily basis. The electronic medical record holds promise here; in many settings these types of logistic challenges can be overcome with electronic tracking, ordering, and scheduling. The process of patient and family participation can be improved by helping ensure that patients are fully educated about the sequelae that may result from critical illness; once they understand the range of difficulties that survivors of critical illness may encounter, they are often highly motivated to attend a post-discharge clinic. This education optimally occurs in a face-to-face context and may be aided by information materials such as brochures that describe the problems represented by PICS.
 
As the number of patients who survive an ICU admission grows, PICS clinics have the potential to become an important part of post-ICU care. There is no standard model that directs the development of PICS clinics, but with more funding and research, outcomes will be measured, and goal-directed, evidence-based models will be created.
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.
2. Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013 Oct;369(14):1306-1316.
3. Jackson JC, Pandharipande PP, Girard TD, et al. 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. 2014 May;2(5):369-379.
4. Davydow DS, Gifford JM, Desai SV, Needham DM, Bienvenu OJ. Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. Gen Hosp Psychiatry. 2008 Sep-Oct;30(5):421-434.
5. Herridge MS, Tansey CM, Matté A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011 Apr 7;364(14):1293-1304.
6. 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.
7. Griffiths JA, Gager M, Waldmann C. Follow-up after intensive care. Contin Educ Anaesth Crit Care Pain. 2004;4(6):202-205.
8. Griffiths JA, Barber VS, Cuthbertson BH, Young JD. A national survey of intensive care follow-up clinics. Anaesthesia. 2006 Oct;61(10):950-955.
9. Cuthbertson BH, Rattray J, Campbell MK, et al. The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial. BMJ. 2009 Oct 16;339:b3723.
10. Schandl, AR, Brattström OR, Svensson-Raskh A, Hellgren EM, Falkenhav MD, Sackey PV. Screening and treatment of problems after intensive care: a descriptive study of multidisciplinary follow-up. Intensive Crit Care Nurs. 2011 Apr;27(2):94-101.
11. Glimelius Petersson C, Bergbom I, Brodersen K, Ringdal M. Patients’ participation in and evaluation of a follow‐up program following intensive care. Acta Anaesthesiol Scand. 2011 Aug;55(7):827-834.
12. Khan BA, Lasiter S, Boustani MA. CE: Critical care recovery center: an innovative collaborative care model for ICU survivors. Am J Nurs. 2015 Mar;115(3):24-31.