Post ICU transitional care Service/Program

As a group, the Post ICU patients present with a unique set of challenges and opportunities for health care providers. Many of these are well-defined and known, while others are poorly defined and relatively understudied. Described here is a model that may help improve outcomes of intensive care not only for patients, but also for their loved ones.

My interest has been in the Concept of Post ICU care Medicine. Managing this patient population in an outpatient setting following their discharge is complex. Setting up and strengthen Post ICU Service/Program requires one to start from the ICU. It is certainly possible to achieve less than 5% readmission rate, which by itself is a huge cost savings for US. Our patients are all ICU survivors with high PICS burden.(National standard for readmission: 15-20%).

After surviving a critical illness, one is at a significant risk of developing a variety of healthrelated problems. These problems fall mainly on the two categories

  1. Problems related to existing medical comorbidities and prescribed treatments
  2. Post Intensive Care Syndrome(PICS)

The first category of medical comorbidities and prescribed treatments related problems may start silently and become apparent at a late stage, hence we recommend a comprehensive medical screening evaluation on the possible risks involved. The next category of problems called PICS can persist for many years and may go unrecognized completely unless one gets a comprehensive evaluation through multidisciplinary approach. This needs very specific knowledge base and skill set and a passion for highest quality care. One needs a thorough education, counselling and highly specific management strategies including use of care coordinators to prevent readmissions, reduce morbidity and lead a healthy life.

POST ICU TRASITIONAL CARE -mainly designed to assist with recovery after being in an intensive care unit. These Patients are at higher risk of having the Post ICU syndrome-a wide range of problems including but not limited to physical, emotional and/or cognitive (thinking/memory). The POST ICU TRASITIONAL CARE can assist these patients and their families with all of their recovery needs. The team ‘s main goal is to recognize and initiate plan of care which will then be transitioned to the primary care physician to manage these needs during their post hospitalization follow up visit.

This is the best way to integrate In-patient team and Out-Patient team along with Family/social Systems to ensure Highest Quality care for the this sickest population. PICS will have high impact on care delivery/compliance if not addressed proactively this way.

The Team

The POST ICU TRASITIONAL CARE team may consist of a nurse practitioner, Clinical Pharmacist, Nutritionist, Social worker, Physical therapist, a Critical care Intensivist, and a caregiver(Family engagement) to ensure that all patient's needs are met.

Patient Selection

Patients are screened for PICS while still in the hospital. This screening process gets initiated following the transfer out of the ICU prior to discharge. PICS can last upto a year or more. The program should be designed to supplement, not replace treatment from patient’s primary care physician or the Hospitalists. POST ICU TRASITIONAL CARE team members communicate with the primary care physician to ensure that treatment is in accordance with his/her medical history and that needs continue to be met once the initial evaluation and treatment with POST ICU TRASITIONAL CARE is complete.

Inclusion Criteria Exclusion Criteria
Sepsis Hospice Patients
Respiratory Failure requiring Mechanical Ventilation NH Placement
Delirium

⃰Both ICU and Non ICU patients can be enrolled into the program
Patients get enrolled into this program during their ICU stay-Database to be maintained electronically. All of the Team members should have access to this. IT can help optimize the needed coordination amongst multiple disciplines. The Patient gets scheduled for a follow up visit (at 2 weeks post discharge)

Comprehensive Evaluation: Objectives

  • Maximize full cognitive, physical and psychological recovery of ICU survivors
  • Enhance patient and caregiver satisfaction
  • Improve the quality of transitional care
  • Reduce Length of Stay in Hospitals, and inappropriate Re-hospitalizations

Each patient in this program undergoes: Initial assessment (In Hospital Pre-discharge) regarding Patient/caregiver needs assessment while the patient is still in Hospital Pre-Discharge

  1. Focused diagnostic work-up including detailed history review, structured physical exam, blood tests and imaging as needed
  2. Comprehensive screening and evaluation for PICS by MDT (see below for details)
  3. Identify factors affecting Length of stay and potential readmission
The team to screen for post ICU Syndrome and initiate a personalized care plan per Multi Disciplinary Team(MDT)

Follow-up (Out Patient Clinic) visit
  1. Patient/caregiver needs assessment 2 weeks Post Hospital Discharge (Review diagnostic work-up done, review detailed history, perform structured physical exam, comprehensive cognitive/psychological/physical assessment, medication reconciliation, blood tests and imaging as needed)
  2. F/u regarding Post ICU Syndrome and evaluate for patient specific challenges in the context of his/her community living and need for continued/additional support
The team (Family conference involving physician, patient, caregiver, and care coordinator/Social Worker) to review personalized care plan coordinated as depicted below

Guide for Post ICU Syndrome(PICS) screening and evaluation by MultiDisciplinary Team(MDT)
MAJOR COMPONENTS (PICS) - Core components of the comprehensive post Intensive care syndrome evaluated by the Multi-Disciplinary Team during their post ICU pre-discharge, inpatient hospital stay are as follows:
Pharm:

  • Medical Reconciliation and Patient/Family counselling
  • Address Poly-pharmacy
PT:
  • Look for Critical Illness Neuromyopathy
  • Gait and Balance
  • Assess for Fall risk
Neuro-Cognitive (Research Assistant):
  • Psychological Assessment-
  • Cognition
  • Anxiety, Depression
  • PTSD
Social worker:
  • Social-Economic Assessment
  • Social support
  • Financial concerns
  • Advanced care preferences
Nutritionist:
  • Caloric Needs
  • Weight change/Monitoring
Intensivist:
  • Round up, review and evaluate need for further evaluation and provide general
  • Counseling including disease specific Counseling, Diet, Supplements, Exercise, Smoking cesation, Alcohol, Sleep hygiene, Injury Prevention

OUTCOMES OF INTENSIVE CARE
ICU patients have higher risk of Morbidity and short-term mortality, the rate of which depends primarily on the admitting diagnosis, the severity of physiological derangement, and the underlying chronic health state of the patient, rather than age itself. For those that survive to hospital discharge, a traditional measure of therapeutic success, subsequent survival trajectories differ markedly from the general population. In other words, survivors of critical illness are at increased risk of morbidity and mortality long after the acute illness has resolved. For example, with severe sepsis, this effect may be seen as far out as a year after the illness.
There have been significant advances in the caring of critically ill patients. Mortality rates for many commonly encountered critical illnesses such as severe sepsis and acute respiratory distress syndrome (ARDS) have declined sharply over the past two decades. However, as greater numbers of patients survive intensive care, it is becoming increasingly evident that quality of life after critical illness is not always optimal.
The sequelae of critical illness (Post ICU syndrome) may include deficits in physical function, cognition, and/or mental health.

Physical Health:
The majority of studies that have examined post-ICU physical function have focused on survivors of ARDS, a population that tends to be younger than general ICU patient populations. For example, Herridge and colleagues found that 1 year after the illness, the majority of ARDS survivors reported persistent functional disability primarily due to nonpulmonary conditions such as muscle weakness and fatigue. Though the distance walked in 6 minute improved over the 12 months after ICU discharge, at 1 year, it was still only two-thirds predicted. Less than half had returned to work. The absence of systemic corticosteroid treatment or ICU-acquired illnesses as well as the rapid resolution organ dysfunction was associated with better functional status during the 1-year follow-up. At 2 years, exercise limitation persisted while health-related quality of life remained below that of the normal population.
Studies that have specifically examined functional outcomes in elderly ICU survivors have been relatively small and methodologically limited, as reviewed by Hennessy et al. An important message from such studies is that elderly ICU survivors, while clearly at risk of post-ICU physical disability, are more frequently satisfied with their post-ICU lives than younger survivors and report preservation of health-related quality of life. intensivists and family members, therefore, should not presume that elderly patients who are either premorbidly functionally limited or likely to suffer from post-ICU syndrome would not want aggressive care during their acute illness. Ideally, such decisions should be made based on the patient’s own expressed wishes. When this is not possible, decision makers should be careful not to discount too heavily the value, or utility, that a functionally impaired life might represent for the patient.

Cognitive Deficits:
Evidence from a variety of cohort studies suggests that 25% to 78% of ICU survivors experience neurocognitive impairments. For instance, nearly half of ARDS survivors manifest neurocognitive sequelae 2 years after their illness, falling to below the sixth percentile of the normal distribution of cognitive function. Considering Terri Fried’s observation that 89% of Americans would not wish to be kept alive if they had severe, irreversible neurologic damage, these findings are quite concerning. In general, difficulty with memory is the most frequently observed deficit, followed by executive function and attention deficits, as shown by Hopkins and colleagues. Impairments tend to improve during the first 6 to 12 months after hospital discharge, with little additional improvement after 1 year. Elderly subjects seem to be at greatest risk, especially in the setting of preexisting mild neurocognitive impairment or dementia. Furthermore, ICU-acquired cognitive insults may accelerate the trajectory of cognitive decline, leading to what some have called “ICU-accelerated dementia.” Data regarding the potential mechanisms underlying ICU-acquired neurocognitive deficits are quite limited, though evidence suggests roles for hypoxemia, hypotension, hyperglycemia, delirium, sedatives, and analgesics.

Psychosocial health:
Psychiatric symptoms and disorders, such as depression, anxiety, and posttraumatic stress disorder (PTSD), affect 15% to 35% of ICU survivors months or even years after their acute medical illness, as reviewed by Weinert. In one study of 154 survivors of >48 hours of mechanical ventilation, 32% suffered from depression (Center for Epidemiologic Studies Depression Scale (CES-D) score ≥ 16) 1 year after their illness. The results were nearly identical to those obtained at the initial 2-month follow-up, suggesting that the burden of depression for ICU survivors may not improve over time. Other studies in survivors of ARDS or other forms of respiratory failure have shown similarly high rates of depression symptoms.
It is not difficult to understand why the experience of critical illness might lead to symptoms of anxiety and PTSD. Similar to combat or natural disaster, there are a number of extreme psychological stresses in the ICU, including fearing of losing one’s life, being routinely subjected to painful procedures, sleep deprivation, drug-induced hallucinations, and a perceived loss of control. Of survivors of ARDS, 28% scored above the threshold value on the Posttraumatic Stress Syndrome Inventory (PTSS-10), which is highly suggestive of the diagnosis of PTSD. Studies of other ICU patient groups, such as survivors of septic shock and those undergoing cardiac surgery, show a similarly high risk of PTSD symptoms. In the ARDS study, those with recall of ICU events seemed to fair worse, suggesting that memories of ICU events were associated with psychologic distress. However, others have shown that the content of recalled ICU memories may be key, in that those with delusional memories and no factual recall appear to be at greater risk of post-ICU depression, anxiety, and PTSD.
Small randomized trials show that depression and posttraumatic stress symptoms can be reduced by interventions during or after critical illness. Kress and colleagues found that mechanically ventilated patients who had their sedation interrupted each day had a trend toward a lower incidence of PTSD (0% vs. 32%, P = 0.06) in addition to shorter duration of mechanical ventilation. Jones and colleagues demonstrated that a self-help rehabilitation manual was effective in aiding physical recovery and reducing depression in survivors of mechanical ventilation. In patients suffering from stroke, two studies have shown that prophylactic administration of antidepressants prevents the emergence of depressive symptoms, even when started several weeks after the stroke. Whether such a preventative approach would work in other ICU patient groups at high risk of depression remains to be seen. It is clear, however, that antidepressants can be helpful in established postillness depression, such as after acute coronary ischemia or stroke.

CAREGIVER OUTCOMES:
More than 40 million Americans serve as informal caregivers to their ill loved ones, and often suffer physical, psychologic, and financial burden as a result. Most evidence for caregiver burden relates to the care of the chronically ill, but studies are beginning to show that informal caregivers of ICU survivors and family members of current ICU patients also have significant burden, including increased risk for depression and PTSD. For instance, in the longest longitudinal follow-up to date of the informal caregivers (n = 169) of critical illness survivors, Van Pelt and colleagues found an elevated and persistent risk of depression, disruption in lifestyle, and reduction in employment over a 12-month period after the onset of critical illness. One-third of caregivers were at risk of depression (CES-D ≥ 16) at 2 months. Although the proportion of caregivers at risk of depression decreased over time, this difference was not statistically significant. At 2 months, only 28.7% of caregivers were employed and 13.0% indicated that they had stopped working in order to provide care. Similar to depression risk, there was no statistically significant change in either employment status or lifestyle disruption over time.
Comparing caregivers of ICU survivors with other caregiver populations provides important insight into the negative impact of critical illness. The findings of Van Pelt and colleagues demonstrate lifestyle disruption and risk for depression that are much greater than that of the general population and similar to caregivers of Alzheimer’s patients. Considering the tremendous caregiver burden that frequently results from caring for those with dementia, these findings underscore the severity of the downstream impairment that can occur after critical illness. This study strengthens growing evidence that the negative societal impact of critical illness goes beyond short-term mortality to include significant lifestyle disruption not only for ICU survivors but also their informal caregivers.

IMPROVING OUTCOMES OF INTENSIVE CARE

The organized ABCDEF approach in ICU care ensures implementation of the key strategies needed for positive outcomes in ICU patients regardless of patient age. Delirium prevention and management strategies, have the potential to reduce medical complications, length of stay, and cost.

The importance of avoiding polypharmacy to prevent dangerous drug interactions and sideeffects cannot be overstated. Yet, review of medications in most ICUs reveals lists that are often much larger.

Prolonged bed rest has well-known adverse physiologic effects, including cardiovascular deconditioning and skeletal muscle atrophy, and prevents anabolic muscle rebuilding. In healthy volunteers, a mere 14 days of bed rest can produce a 1.7% decrease in lean body mass, with a 4.1% decrease in lean thigh mass. After 6 weeks of bed rest, 25% to 30% of quadriceps strength is lost. Critical illness and exposure to corticosteroids, only makes this worse. Hence, Early mobility should be encouraged

Because of the nature of critical illness and the modalities used to manage it, prolonged bed rest somes times is unavoidable-nonnegotiable for most part in the ICU. Physical rehabilitation, which has the potential to restore lost function, is traditionally not started until after ICU discharge. Bailey and colleagues evaluated the safety of early physical activity in 103 patients (mean age 62.5 years) with respiratory failure who required >4 days of mechanical ventilation. Remarkably, nearly 70% of survivors were able to ambulate >100 ft before ICU discharge. Since the ability to ambulate is often an important determinant of a patient’s ability to return to home, this finding is worth noting. Participation in activity was not limited by advanced age, or being on Ventilator. Adverse events were infrequent, easily addressed.

Patient/Family satisfaction:
Family satisfaction is an important measure of the quality of ICU care. Yet, attention to objective measurement and improvement of family satisfaction is a relatively recent phenomena in the ICU. Physician–family communication is possibly the most important factor driving family satisfaction. Other factors that may improve family satisfaction include allowing family members more time to speak during conferences, avoiding contradictions in provided clinical information, helping resolve conflicts among family members, and implementing flexible visitation policies.

Having a loved one in the ICU is an immensely stressful. Effective communication between caregivers and families and having support from caregivers throughout the decision-making process is important to family members. Such communication and support are sometimes inadequate due to the many competing priorities in a busy ICU. Lautrette and colleagues evaluated the effect of a proactive communication strategy in family members of 126 patients dying in 22 ICUs in France. The intervention consisted of an end-of-life family conference conducted according to specific guidelines and that concluded with the provision of a brochure on bereavement. In the control group, interactions between the family and the ICU staff, including the end-of-life conference, occurred according to the usual practice at each center. It was noted that those in the intervention group had longer conferences and more time for family members to talk. Furthermore, intervention family members had decreased symptoms of anxiety, depression, and PTSD 90 days after the patient’s death, suggesting that the intervention may lessen the burden of bereavement.

ICU follow-up clinics have been proposed as a means of identifying and addressing the myriad of potential late sequelae that elderly ICU survivors may face. While still uncommon in the United States, as many as 30% of ICUs providing care to high-level ICU patients in the United Kingdom offered outpatient follow-up their patients in 2006 as shown by Griffiths and colleagues. ICU follow-up clinics can be nurse or doctor-led and are commonly run on multidisciplinary lines, with patients potentially benefiting from inputs that include physical therapy, dietetics, urology, ear, nose, and throat (ENT), psychology, and psychiatry. Where extended ICU follow-up exists, patients report great satisfaction with the service.

Screening Tools

  1. Montreal Cognitive Assessment (MOCA)
  2. Hospital Anxiety and Depression Scale (HADS)
  3. PTSD Check List- Civilian Version (PCL)
  4. Instrumental Activities of Daily Living (IADLs)
  5. Physical Self-Maintenance Scale/Activities of Daily Living (ADLs)
  6. Get Up and Go Test Performance Oriented Mobility Assessment

Useful Screening Tools Download

Reference articles

Quality of Life in Adult Survivors of Critical Illness: A Systematic Review of the Literature.
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Quality of Life after Intensive Care: A Systematic Review of the Literature
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Improving Long-Term Outcomes after Discharge from Intensive Care Unit: Report from a Stakeholders’ Conference
Critical Care Medicine 40, no. 2 (February 2012): 502–9. doi:10.1097/CCM.0b013e318232da75

Long-Term Cognitive Impairment after Critical Illness’
The New England Journal of Medicine 369, no. 14 (3 October 2013): 1306–1316. doi:10.1056/NEJMoa1301372

Rehabilitation Interventions for Postintensive Care Syndrome: A Systematic Review
Critical Care Medicine 42, no. 5 (May 2014): 1263–71. doi:10.1097/CCM.0000000000000148

What happens to patients with COPD with long-term oxygen treatment who receive mechanical ventilation for COPD exacerbation? A 1-year retrospective follow-up study
Thorax. 2014 May 14

Increased 1-year healthcare use in survivors of severe sepsis
Am J Respir Crit Care Med. 2014 Jul 1;190(1):62–9

Long-term cognitive impairment after critical illness
N Engl J Med. 2013 Oct 3;369(14):1306-16. doi: 10.1056/NEJMoa1301372

An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study
Crit Care. 2013;17(3):R100

Acute Outcomes and 1-Year Mortality of Intensive Care Unit-acquired Weakness. A Cohort Study and Propensity-matched Analysis
Am J Respir Crit Care Med. 2014 Aug 15;190(4):410–20

Association of postdischarge rehabilitation with mortality in intensive care unit survivors of sepsis
Am J Respir Crit Care Med. 2014 Nov 1;190(9):1003–11

Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study
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