THRIVE: Accomplishments, Challenges, and Next Steps

2016 - 6 December – Survive and Thrive
Mark E. Mikkelsen, MD, MSCE; Theodore J. Iwashyna, MD, PhD, FCCM; Carol L. Thompson, PhD, DNP, ACNP, FCCM, FAANP; Adair Andrews, RN, MATD
Learn about the accomplishments, challenges, and next steps for the THRIVE initiative.
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In January 2015, the Society of Critical Care Medicine’s (SCCM) THRIVE Initiative was launched in Phoenix, Arizona, USA. THRIVE’s objective is to improve the post-intensive care unit (ICU) experience of survivors of critical illness as a natural extension of SCCM’s mission to “secure the highest-quality care for all critically ill and injured patients.” THRIVE is an institutional response to the success of modern-day critical care (critically ill patients are now far more likely to survive) paired with the emerging literature on post-intensive care syndrome (PICS) and the challenges faced by survivors and their loved ones.
 
Pragmatically, THRIVE was based on three core objectives: 1) to develop new approaches to supporting survivors, 2) to educate both SCCM and the broader medical community about survivors’ needs, and 3) to accelerate research specifically focused on ICU survivorship. A crosscutting objective was to find new barriers our patients face and new solutions of which we were unaware when THRIVE was commissioned. To achieve these objectives, THRIVE includes volunteers from nursing, internal medicine-based critical care, surgical critical care, anesthesia critical care, critical care pharmacists, neuropsychologists, palliative care, and survivors themselves.
 
THRIVE’s initial approach to supporting survivors was the development of the Peer Support Collaborative. In autumn 2015, six sites (five adult and one pediatric) were selected as part of the inaugural Peer In-Person Support Collaborative. In autumn 2016, we welcomed 11 new sites, including four international sites (Scotland, two in England and Australia), into the second Collaborative with continued participation by most of the original sites. These groups are trying a variety of models of peer support, trying to learn how to match a model to a local patient population and the available resources. This process involves regular phone and in-person meetings, development of each group’s own data reporting structure to track progress, and structured reflection to coalesce institutional lessons learned and share them with others, this latest point hopefully forthcoming as a manuscript next year (2017).
 
Already, several lessons have emerged from these efforts. Four examples are included here. First, many survivors, once home, remain limited in their ability to connect with others and share their experiences. These limitations vary from functional to financial, and together make in-person support challenging. Second, it is very common for survivors’ home finances to be in disarray, not only from hospitalization costs, but from work time lost by family members to caregiving and even the loss of passwords and other challenges of running a household. Third, many ICU survivors do not immediately identify with critical illness as a formative experience but, once introduced to the concept, find the commonality of experience across the variety of critical illnesses very useful. Finally, we have learned that there is a substantial burden to running an in-person support group, more than is probably sustainable on a purely unfunded basis by volunteer clinicians.
 
THRIVE has developed two additional exploratory programs: a pilot virtual support program, and a new collaborative to support innovations in post-ICU follow-up clinics. On September 13, 2016, THRIVE launched its first virtual support group, led by THRIVE member Alison Clay, MD. The growth of these pilot virtual support groups is steady. The immediate impact to those who attended was inspiring. As a result, the virtual support groups are now being held every two to four weeks. This promising strategy for supporting survivors demonstrates the inherent flexibility incorporated into the THRIVE initiative to meet the needs of survivors, but will need to be scaled carefully and slowly.
 
THRIVE is launching a Post-ICU Clinic Collaborative to support learning about this potentially high-value (but also costly) approach. The THRIVE symposia at Congress, scheduled for Sunday, January 22, 2017, will explore the promise of post-ICU clinics as a means to better understand and meet the needs of survivors. Inaugural sites will be selected in March 2017, and the Collaborative will launch thereafter. THRIVE’s second strategy to better meet the needs of survivors is its educational and partnership activities.These activities aim to integrate survivorship, recovery and awareness of PICS into SCCM educational activities and to disseminate knowledge outside SCCM as well. After a well-attended session held at Congress in Orlando, Florida, USA, in 2016, two THRIVE-related sessions have been programmed for the upcoming Congress, on Sunday, January 22, 2017, in Honolulu, Hawaii, USA.
 
At the opening session, Nalini Nadkarni, PhD, will deliver the Peter Safar Memorial Lecture titled “‘Fallen’: A Transdisciplinary Tale of Disturbance and Recovery.” She will discuss her own critical illness experience and recovery after a near-fatal fall from the top of the rain forest canopy, and will relate discoveries from her life’s work on disturbance and recovery in diverse ecosystems to the SCCM THRIVE initiative. After the opening session closes, the “THRIVE ICU Aftercare Service: An Essential Part of Our Care” symposium, moderated by Carla M. Sevin, MD, of the Vanderbilt Recovery Center, will be held from 8:30 a.m. to 10:30 a.m.
 
The THRIVE website, www.myicucare.org/Thrive, has undergone significant development, although it remains in an early stage. The site includes new, brief informational videos and content that can be viewed and downloaded to educate clinicians, patients and families throughout the recovery process, beginning during the ICU stay. Content design was guided by the experience of THRIVE members, as well as an in-person needs assessment conducted with post-ICU survivors and families at the Vanderbilt Community Engagement Studio in Nashville, Tennessee, USA, in May 2016. THRIVE designed YouTube videos have been created for PICS, titled “THRIVE: Redefining Recovery,” “Wellness,” and “What to Expect After Discharge.” In parallel, to raise awareness of PICS outside SCCM, THRIVE is partnering with other, non-critical care organizations to ensure that information about PICS is presented at their annual meetings.
 
THRIVE’s third strategy to accelerate closing the gap is to stimulate innovative research in recovery from critical illness and to acknowledge pioneers who are leading the way to meet the needs of survivors. Through generous SCCM funding, the inaugural THRIVE research grant was awarded to Bradford D. Winters, MD, an intensivist physician from Johns Hopkins University, to conduct a multicenter study to understand the ICU and recovery experience of critically ill patients receiving mechanical ventilation. The second was awarded to Kimberley Haines, PhD, an ICU physiotherapist and Allied Health Research lead, of Western Health in Melbourne, Australia. She will be evaluating and conducting a pilot randomized trial of a co-designed survivor support program. The inaugural THRIVE Innovation award was bestowed on the Vanderbilt Recovery Center at Congress 2016, and the second award will be bestowed on Babar A. Khan, MD, of Indiana University, at Congress 2017.
 
We are at a tipping point in critical care survivorship. Awareness of PICS has spread throughout the critical care community. However, awareness is quite limited among clinicians who encounter survivors post-ICU and throughout the long process of recovery. We have more and more rigorous data on the problems, but, as in so many other ICU conditions, from acute respiratory distress syndrome to sepsis, few proven therapies to fix these problems. THRIVE is primed to speed the move of our professional community from the stage of problem definition to that of trying and evaluating innovative solutions. At the same time, survivors’ voices are being heard more clearly and more loudly than ever; SCCM and THRIVE are positioned to amplify their voices, to share their experiences and to accelerate the knowledge and support necessary to facilitate a meaningful and enduring recovery. As THRIVE evolves and matures, the objective to “secure the highest-quality care for all critically ill and injured patients” beyond the ICU can be realized. And, throughout the process, the bricks that form the insurmountable wall that survivors now face can be reused to build the path to recovery.