Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: Over the last decade, we have seen significant advances in critical care medicine,
Speaker: These advances have resulted in a growing population of ICU survivors.
Speaker: As intensivists, we have been very good at focusing on immediate threats to our patients and solving urgent clinical issues.
Speaker: However, this short-term focus may have contributed to us not recognizing the complexities and difficult road critical care survivors have once they leave our ICUs.
Speaker: Today, we will talk about what happens to critical illness survivors.
Speaker: Our guest is Dr. Carla Sivin,
Speaker: director for the ICU Recovery Center at Vanderbilt, medical director for the Pulmonary Patient Care Center, and an assistant professor of medicine at the Vanderbilt School of Medicine.
Speaker: Her professional interest and experience focused strongly on inpatient pulmonary and critical care medicine, as well as the care of patients after critical illness.
Speaker: Since 2001, she has led the development and implementation of the ICU Recovery Center at Vanderbilt.
Speaker: In addition to her clinical work,
Speaker: She has worked with the Thrive Task Force for the Society of Critical Care Medicine to further awareness, research, and education about post-intensive care syndrome, or PICS, and in 2017, started the Thrive Post-ICU Clinic Collaborative.
Speaker: Through these efforts, she has had the opportunity to speak with patients, caregivers, intensivists, primary care physicians, allied health professionals, and hospital administrators about the pressing need to define this syndrome and develop a means to diagnose and treat it.
Speaker: She's a true pioneer in defining the role of ICU aftercare programs in our changing healthcare environment and an expert in the benefits and barriers to creating such programs and practice.
Speaker: Carla, welcome to Critical Matters.
Speaker: Thank you so much for having me.
Speaker: So I think that, as usual, a great place to start is defining what we're going to be talking about today, which is the post-intensive care syndrome.
Speaker: So when I say post-intensive care syndrome, what do you think about
Speaker: Well, there is a specific definition, which is really what I should say is a nonspecific definition because it's pretty vague, but it's a name that we tried to put on a constellation of symptoms that we were seeing in patients who had survived a critical illness.
Speaker: So the definition is newer worsening impairment in cognition, mental health, or physical function, any of those three domains, after critical illness, and something that persists beyond the acute hospitalization.
Speaker: And one of the things that I have noticed as we become better in caring for these patients, for critically ill patients, there's more survivors, is that we also have seen the emergence of new categories of patients, such as the chronically critically ill or the hospital-dependent patient.
Speaker: Would those patients fall in this category, or we're talking about a separate population within survivors?
Speaker: Well, those conditions can certainly coexist in the same patient, but not at the same time.
Speaker: So chronic critical illness and a chronically hospitalized person is still dependent on some sort of life support, usually mechanical ventilation, that's keeping them institutionalized, perhaps in a long-term acute care facility or a nursing home that does ventilator support.
Speaker: But the patients who have post-intensive care syndrome are, by definition, have left the hospital
Speaker: and are trying to return to some kind of baseline and are struggling with impairments in these domains.
Speaker: So I think that's an important aspect just to make sure that the audience understands who we're really talking about.
Speaker: So this would be really patients who have graduated from the ICU, left the hospital, perhaps a short stint in rehab, but are really back home trying to get back to what normality would be for their lives.
Speaker: Is that correct?
Speaker: That's right.
Speaker: Before we go into the details about the specific domains, you talked about three components, cognitive, psychiatric, and physical functioning.
Speaker: Why is this important?
Speaker: Why should we care as intensivists?
Speaker: What's happening with these patients?
Speaker: Well, this is really a hidden public health problem.
Speaker: I would say a public health catastrophe.
Speaker: There are about five million people each year who are at risk for this so-called syndrome, post-intensive care syndrome.
Speaker: That's about three times the number of people who get a new cancer diagnosis in this country every year.
Speaker: So this is a huge population, but it really runs under the radar.
Speaker: And part of that is because we, as intensivists,
Speaker: don't really acknowledge or have good awareness of what post-intensive care syndrome is or that our patients would have any sequela after the ICU.
Speaker: And then, you know, the patients are being seen by primary care doctors, if anybody, and those physicians don't necessarily have a lot of time or education dedicated to this problem.
Speaker: And then, worst of all, patients and families themselves have
Speaker: no name for the problems that they're experiencing.
Speaker: As one patient told us, I didn't even know what to Google because I didn't know the name for the problems that I was experiencing or necessarily understood that they were related to my critical illness or my critical care.
Speaker: So as you said, a big number of patients, a big under-recognized population, and it seems that
Speaker: a big failure in terms of being connectivity and follow-up care with the people who are seeing these patients and knowing what can happen to them after surviving critical illness.
Speaker: And I guess a failure on our part in not really recognizing what happens once they leave the ICU.
Speaker: Absolutely, and I really love talking to other intensivists in other parts of the country and other parts of the world.
Speaker: And even, you know, after I give a talk about post-intensive care syndrome with all kinds of examples from my own patient population, almost invariably there's a comment in the audience that says, well, this doesn't really apply to my patients because they don't have these problems, and I know this because they don't come back.
Speaker: And I think that is a false assumption to assume that if you're not seeing your patients again, that they're not having these problems.
Speaker: First of all, they can't come see you because we don't
Speaker: Most of us who work in ICU don't necessarily have an open opportunity for patients to come see us after the ICU, either as a regular outpatient or in a structured post-ICU clinic.
Speaker: And also, a lot of patients lack awareness.
Speaker: Part of the cognitive dysfunction, which I'm sure we'll get into a little bit, is that they lack awareness of their deficits
Speaker: and lack the executive function to try to seek help for the problems that they're experiencing.
Speaker: But that doesn't mean that they're not having problems.
Speaker: And I think that it's very interesting.
Speaker: You mentioned that patient that didn't know what to Google.
Speaker: But I think it speaks of a not uncommon pattern in disease where a lot of patients, especially with some of these newly identified syndromes or anything that affects their psyche, believe that it only happens to them.
Speaker: And then they're extremely surprised to find out that, like you mentioned, millions of patients who've been through a similar experience are having similar problems.
Speaker: And I think it just speaks to how little we know about this.
Speaker: Absolutely.
Speaker: And even if we don't have great treatments to offer, being able to name something and educate patients and reassure them that this is not normal, but it is a common side effect of being in the ICU is very important.
Speaker: provides a lot of reassurance to patients and their families.
Speaker: So Carla, before we dive in a little bit more into the specific components of PICS, can you tell us a little bit about, I also have seen in the literature, the emergence of PICS-F, or post-intensive care syndrome for families, and tell us what that is.
Speaker: Yeah, this is a really interesting concept, which I think is, even for people who think about post-intensive care syndrome a lot, kind of the next frontier in the areas that we need to research, understand, and treat.
Speaker: So in the ICU, we're very comfortable talking to families and developing close relationships with families over the course of a critical illness.
Speaker: We're constantly updating them about their family member's condition, and we kind of form a tight bond with a lot of these families through
Speaker: the trauma of critical illness.
Speaker: And yet, when we see patients in the outpatient setting, if we do indeed see patients in the outpatient setting,
Speaker: there's a lot of uncertainty about our relationship with the family.
Speaker: Are they our patient?
Speaker: Are they our subject?
Speaker: Should we be seeing them together with the family or separate?
Speaker: Should we be administering screening tools to the family members?
Speaker: And I think all that needs to be worked out.
Speaker: But certainly families are suffering equally in post-intensive care syndrome.
Speaker: Perhaps even more, we have certainly experienced in some families where the patient has no recollection of the ICU stay, but the family members are suffering incredibly from post-traumatic stress due to having, unfortunately, been awake for the whole episode and having these really existential threats to themselves and their family members.
Speaker: Certainly, the post-intensive care syndrome can affect families directly in the effects that family members experienced while they were in the ICU, but then also indirectly in the post-ICU period where we're discovering how
Speaker: relationships and roles within the family and in society really are changed and impacted by the critical illness.
Speaker: And with some funding from the Society of Critical Care Medicine, we're just completing a qualitative study that interviews patients and clinicians, but also family members, about what actually helps them and what hurts.
Speaker: them in the post-ICU recovery period.
Speaker: And a lot of what has come up is this changing of roles and the conflict that comes up in the family.
Speaker: And some of this can be quite severe, resulting in the end of relationships and even marriages, and is, I don't think, something that we can ignore when we're trying to address problems in the post-ICU period.
Speaker: And I think also what's interesting, at least from my perspective, and I would love to hear your comments on the family involvement or the PICS-F, is that it may also happen in the families of non-survivors.
Speaker: So these are usually people that truly fall off our medical radar, patients who die, but the family might have severe consequences for months to come related to that ICU stay.
Speaker: Yeah, absolutely.
Speaker: And we have nothing for those people, right?
Speaker: We don't have any entree for them back into the medical system.
Speaker: I've had, on rare occasions, a family member call and just want to, you know, call my office and want to talk about certain aspects of the critical illness course in their person who died.
Speaker: And, you know, I'm hearing a big
Speaker: medical center in Nashville at Vanderbilt, and so sometimes I run into family members in the medical center or in the town after their person has died.
Speaker: But those are really superficial interactions, and we really have nothing in terms of knowledge or therapy for that group of patients.
Speaker: And I think that like many other things that we're learning in critical care, the first step, like you said, is awareness and being able to recognize and share this information because even though we don't see these family members, primary care physicians do see them.
Speaker: And being able to recognize that the critical illness of a loved one may have an impact on their own patient is, I think, something that obviously we need more of our primary care physicians to recognize and understand.
Speaker: Yes, I agree.
Speaker: And I think, you know, our primary care partners, I can't admire the job that they do enough.
Speaker: And they're so well-versed in kind of the holistic approach to patients and families.
Speaker: And you're right, they are the ones who are providing most of the post-ICU care for patients or families, at least in the United States.
Speaker: And we could do a better job of supporting them in that.
Speaker: So before we go into more of the risk factors and start talking about prevention and other strategies, could you dive in a little bit deeper, Carla, into the three domains that you mentioned?
Speaker: So the syndrome is a new or worsening symptom in a cognitive function, psychiatric function, or physical function.
Speaker: Could you give us concrete examples of what are some of the things that our patients go through in those domains once they leave the ICU that you're seeing on a regular basis?
Speaker: Sure, and let me just preface this by saying that we try to see patients quite early after the ICU, so these deficits are probably most severe in that time course, but they evolve over time.
Speaker: The things that we see most commonly are I'll start with the physical function since that's something that's probably the most familiar to us as physicians.
Speaker: This population is routinely weak.
Speaker: We do a six-minute walk test to get a kind of idea of what their global physical functioning is and endurance.
Speaker: That's routinely 50% predicted or lower in the post-ICU period.
Speaker: includes all comers from, you know, 18-year-old dock workers to 90-year-old church ladies.
Speaker: You know, the physical impairments are profound.
Speaker: And even sometimes after a relatively short ICU stay, which is interesting, and some of the risk factors that we see for the critical illness, myopathy, and polyneuropathy weakness is, as you would expect,
Speaker: getting steroids, getting paralyzed, prolonged immobility, a lack of early mobility or aggressive rehab, certain medications, hypoxia.
Speaker: ECMO is, you know, something that we're starting to do more at our center, and those patients are really the sine qua non of the post-ICU weak patient.
Speaker: And this weakness in the peripheral neuropathies can have a lot of downstream effects.
Speaker: So, for example, if you can't weat, if you can't walk and you can't feel your feet, you can't drive, your reaction time may be slow, you can't get to work.
Speaker: You know, we're a car-based society.
Speaker: So unless you have a lot of support, even just the weakness in isolation,
Speaker: can have a profound impact on your life and your ability to get back to your normal function.
Speaker: And the really sad part about it is that there's only one treatment, right, that's inpatient or aggressive rehab, whether it's inpatient or outpatient.
Speaker: And for a variety of reasons, you know, our patients don't always get as aggressive a rehab program as they need to get back to their baseline function.
Speaker: And what is paid for by insurance
Speaker: or covered by the hospital may be just the barest minimum.
Speaker: I like to tell my patients who, you know, we started doing the six-minute walk test just out of scientific curiosity to see if our pragmatic clinical population was as weak as what was described in the literature, and they were.
Speaker: But what was interesting is that the patients responded very interestingly to having some objective data
Speaker: some objective measurement of their weakness.
Speaker: So, you know, they would say, I'm fine, I'm going back to work.
Speaker: And I would say, well, your six-minute walk distance is 47% predicted.
Speaker: And they're like, oh, my God, 47%.
Speaker: And that really motivated them to do the only treatment, which is more physical therapy, even though that is difficult and often expensive to do.
Speaker: But I like to tell them about one of our super survivors who was on the vent for 18 days.
Speaker: She had high dose steroids, she was very, very weak and had persistent respiratory failure.
Speaker: Went to an LTAC, went to inpatient rehab, went to outpatient rehab, and after her outpatient rehab ran out, she hired a trainer and went to the gym for 180 straight days.
Speaker: And, you know, unfortunately, that is sometimes what is required.
Speaker: And I think that your findings with a six minute walk test, I think it really touches on several, I think, important points.
Speaker: One is that both patients and ourselves probably are overestimating what patients can really do.
Speaker: And when you get objective data, it's like irrefutable.
Speaker: Wow.
Speaker: I mean, right.
Speaker: 47%.
Speaker: That's not so good.
Speaker: And number two, I think, like you said, in terms of motivation, having an objective target, I can see it's improving.
Speaker: So it was 47 and now it's 67.
Speaker: I still have a far way to go, but I made significant improvement.
Speaker: And I think that that's something that also might be very useful for patients just thinking of that in that way.
Speaker: Right.
Speaker: And conversely, I've had a couple of patients react kind of angrily like, hey, I thought I was doing better.
Speaker: And now you're telling me this is so bad and I feel terrible.
Speaker: And, you know, they were kind of depressed about it.
Speaker: But then on subsequent visits, they had really taken that advice to heart and gotten better and then seen that improvement and were very, you know, felt very validated by that.
Speaker: Excellent.
Speaker: What about the cognitive and psychiatric aspects of the syndrome?
Speaker: Yeah, so the cognitive function and the psychiatric function, you know, I'm not a neuropsychologist and I didn't go to a psychiatry residency, so a lot of this I had to learn from some of my excellent colleagues in those fields, including Jim Jackson, who works with me in the clinic.
Speaker: So we do a brief cognitive screen and sort of psychiatric, some psychiatric diagnostics.
Speaker: in the clinic.
Speaker: The cognitive screen is very, very interesting to me.
Speaker: So, you know, we all learn the mini mental status exam in medical school, and I think that's probably the lowest level cognitive screen that you can do.
Speaker: But even that is markedly abnormal in a subset of our patients.
Speaker: Interestingly, though, I've had some delightful conversations with people, and I did not find them at all impaired, especially people who were previously high-functioning.
Speaker: And then Jim would go in and ask these many mental status questions or the Montreal Cognitive Assessment, which is MOCA, and they were dramatically abnormal.
Speaker: We had a patient who was very high-functioning who had already returned to work part-time,
Speaker: Both I and his wife were pretty stunned to hear that he didn't know the ear or who the president was.
Speaker: So I think the lesson there is that you have to ask these specific questions in order to assess cognitive function.
Speaker: And certainly you can, you know, there is an eight-hour neuropsych evaluation that can be done to evaluate cognitive function in depth, but that is, in my opinion, not what is needed so much as sort of
Speaker: gross estimation of whether this person is having deficits severe enough that they require, you know, additional therapy or at least some counseling that perhaps now would not be a good time to go back to work as a CFO or whatever their job was before they got sick.
Speaker: So the cognitive function, especially in the domains of executive function, is highly affected.
Speaker: And again,
Speaker: Even in young people with a relatively short ICU stay, we can see some pretty profound changes in cognitive function.
Speaker: And the therapy for that is not clear cut.
Speaker: We're working on, you know, some cognitive rehab that can be done, and certainly there are some resources that you can refer patients to in the community.
Speaker: But I think the identifying, naming, and counseling patients and families is probably
Speaker: the best thing that we can do in the early post-discharge period.
Speaker: It also helps, as you alluded to, the PICS family, it really helps relationships within the family when you can name cognitive deficits as the reason why your loved one is going to the store and coming back with none of the things that you asked for.
Speaker: It really helps intervene on some of the intrafamilial conflicts that can arise after critical illness.
Speaker: And I think that that's a great example of something that we tend to totally underestimate.
Speaker: We have conversations with some of our patients.
Speaker: They're highly functioning people at baseline, and it seems everything's okay.
Speaker: But when you dig a little bit deeper and use the right tools, you're surprised to find that there's significant problems there.
Speaker: And I think that that's something that we really haven't thought about much as a community of intensivists with a lot of the people who leave the ICU.
Speaker: So definitely important.
Speaker: What about from a psychiatric standpoint?
Speaker: So in the psychiatric realm, all of the things that we think of as being your major psychiatric diagnoses, anxiety, depression, and PTSD are all found at higher rates in the post-ICU population than in the general population and even some other sick populations.
Speaker: Interestingly, we looked at our first three years of patients
Speaker: that we saw in clinic, which is admittedly a somewhat self-selected population.
Speaker: This was a clinical population, not a study population.
Speaker: So, you know, you had to have the wherewithal to actually get to clinic to be seen.
Speaker: But we saw a lot more anxiety than PTSD.
Speaker: The PTSD rates were lower
Speaker: and the anxiety rates were higher compared to the published literature.
Speaker: And we think that's because we were seeing people so soon after the ICU.
Speaker: So a lot of anxiety after a critical illness is, I think, to be expected.
Speaker: But if it goes unchecked or untreated, then it can evolve into PTSD.
Speaker: So that's one area where we can potentially be intervening in the post-ICU period if we see patients soon enough and actually preventing some of these long-term problems.
Speaker: And some people, of course, also have pre-existing psychiatric problems before they get critically ill, and teasing those out is something that we try to do, although, you know, not to the extent that you would do in an appointment that's purely psychiatric.
Speaker: And I would also say, you know, I'm very lucky to have a neuropsychologist in my clinic, but I don't think it's necessary to have a neuropsychologist, you know, if you're saying,
Speaker: I'm not going to see my patients after the ICU because I don't have a neuropsychologist.
Speaker: A lot of these tools can be done, you know, by anybody or somebody who's trained a speech therapist, do a lot of cognitive evaluations, social workers, and, you know, other counselors could administer some of these tools for you and help you at least get an idea of what the problems are for your patient.
Speaker: And in terms of how you see these present, Carla, they're all linked to each other.
Speaker: I would imagine that the more physical dysfunction I have, the more I recognize I have difficulty with my cognitive function, the more anxious or depressed I would get.
Speaker: Do you see them all interconnected just as the overall burden of critical illness, or are some more prevalent sometimes in the individual patients based on different factors?
Speaker: Yeah, they certainly can be, but they don't have to be.
Speaker: And some people have, you know, their physical function is right on track, and their cognitive function is doing pretty well, but they have debilitating anxiety related often to the fear of getting sick again, getting re-hospitalized again.
Speaker: So certainly you can imagine if your physical function is quite bad, you're going to be depressed, and that's going to affect your cognitive function.
Speaker: So they certainly can be tied into each other.
Speaker: As much as I would say that these patients are more alike than they are different, there are certainly some unique characteristics from patient to patient, depending on their situation.
Speaker: And in terms of risk factors, you did mention some of them earlier, and obviously the burden of critical illness itself, I'm sure, is a big driver of this.
Speaker: But could you comment on some other risk factors that might be of interest or particular that you've seen with your research and your experience in these three domains or for PICS as a whole?
Speaker: Yeah, so we actually, you know, when we started our clinic, we didn't really have a good model for how to recruit patients for the clinic, but we knew what some risk factors were for especially the cognitive dysfunction in the ICU.
Speaker: And certainly delirium is a massive risk factor.
Speaker: It portends poor prognosis overall.
Speaker: Those patients are more likely to have morbidity and mortality related to their
Speaker: critical illness, but it also predicts more cognitive dysfunction after the ICU.
Speaker: So if I see somebody in the ICU who is delirious, especially if they have prolonged delirium, so the time that they're delirious is correlated with outcome as well, then I am definitely going to try to get them to come back to clinic so that we can assess their function after the ICU.
Speaker: And some of the risk factors, just like the domains of impairment, are paired together.
Speaker: So if you're on mechanical ventilation, you're probably going to be sedated, so you're more likely to have delirium.
Speaker: And all of those things are risk factors for poor prognosis and for PICS.
Speaker: Others would be hypoxia.
Speaker: Again, maybe you're on a ventilator because you're hypoxic.
Speaker: Sepsis and
Speaker: shock.
Speaker: So I mean, obviously these are all things that are very common in our ICUs and understanding the risk factors and understanding why these people develop this syndrome I think is the first step in trying to prevent it from happening.
Speaker: So most of our audience, I suspect, does not practice in an ICU survivor clinic, but they do practice in ICUs.
Speaker: So what are the things that we can take care on a daily basis or things that we should be focusing on a daily basis
Speaker: to try to lessen the or mitigate the likelihood of them having severe PICS once they leave the ICU.
Speaker: Can you talk about some of those interventions that we should be focusing on as a preventive measure?
Speaker: Right.
Speaker: Well, first of all, number one, do your day job.
Speaker: Provide excellent critical care, right?
Speaker: Because if the patient doesn't survive, we're not going to have any of these problems.
Speaker: And I don't want to suggest that we should not be, you know, focusing on critical care.
Speaker: But while we're doing that,
Speaker: preventing delirium and other complications of our care can have a big impact on these patients for their long-term recovery.
Speaker: So, you know, not that long ago, even, you know, when I was training, people would be delirious and we'd be like, well, they're delirious, you know, there's nothing we can do about it.
Speaker: And we didn't really understand what a bad marker of disease that was.
Speaker: But now that we know that, we should be very aggressive in trying to prevent that, and that means trying to organize our units to have the lights on during the day and try not to interrupt sleep at night and avoid delirogenic drugs, which for the most part are going to be sedative.
Speaker: So, you know, avoid benzodiazepines when we can and keep our patients as minimally sedated as necessary.
Speaker: to protect their life support devices, treat pain, which is a cause of delirium, and then, you know, prevent other complications of our care that can extend from the critical illness like clots and pressure sores and bleeding and malnutrition and hospital-acquired infections, all of which will extend the critical illness and thus the risk for impairment after the hospital.
Speaker: So one of the emphasis from the Society of Critical Care Medicine and has been the topic of previous podcast episodes has been the implementation of the ATF bundles or the ABCDF bundles, which include a lot of the things that you're mentioning.
Speaker: I know that there's data suggesting that there's a dose response to the implementation of these bundles in terms of short-term outcomes that are very important for our patients.
Speaker: Do we know what effect they have on the incidence or the severity of PICs?
Speaker: Yeah, so we're looking at that again.
Speaker: You know, we're a little bit stuck with this definition of PICS, which is kind of vague.
Speaker: And we don't have a PICS screening tool that we can deploy out into the community and say, you have PICS, you don't have PICS.
Speaker: So it's very difficult to study PICS as a whole, although, you know, there is some research looking at various aspects of PICS, for example, the cognitive function.
Speaker: So absolutely, by implementing the ADEF bundle, you will decrease
Speaker: delirium and therefore improve long-term cognitive outcomes.
Speaker: But, you know, whether you can say in general people will have less PICs, I can't point you to the evidence that that is true, but I suspect that is true because, again, if you're not delirious and you're not being sedated as much, you're going to come off the vent sooner, you're going to be out of the ICU sooner, you're less likely to have these post-ICU complications.
Speaker: So it seems logical that we would be decreasing a number of long-term adverse outcomes by implementing these bundles.
Speaker: And Carla, we talked a little bit about how you screen for this, but can we maybe expand on the diagnosis and recognition and more about like the specifics?
Speaker: How do you identify it in these high-risk patients?
Speaker: When do you test first?
Speaker: I'm just curious how you do it in your practice.
Speaker: Yeah, absolutely.
Speaker: Well, like I said, there's no validated screening tool for PICS per se.
Speaker: There are certainly a lot of existing tools that are out there, and the clinic collaborative that we host through SCCM is trying to put together a kind of toolkit so that you can see who is using what.
Speaker: But most teams who are seeing post-ICU patients have employed a variety of these existing tools to try to pinpoint deficits in the various domains.
Speaker: So the other question is, when do you test?
Speaker: So some of the earliest data for post-ICU impairment really came out of the UK, where they tried to implement post-ICU programs quite early, like 20 years ago or 30 years ago in some cases.
Speaker: But most of those assessments were done quite distant from the ICU stay, even three or six months after the patients went home.
Speaker: We see patients very early.
Speaker: after the ICU stay, and that is clearly a different set of problems, especially in the U.S. We have very fragmented care.
Speaker: We have a lot of patients who don't have an established relationship with a primary care doctor, and there's just a lot of care that falls through the cracks in the immediate post-hospital period.
Speaker: So all the things that you're writing for your patients at discharge that you think that they're getting,
Speaker: like their flu shot and their rehab and their DME and their home health, in many cases, they're not actually reaching the patient.
Speaker: And there's, I think, a lot of low-hanging fruit there in terms of what we can intervene upon.
Speaker: On the psychological side, like I said, we see more anxiety than PTSD early after the ICU.
Speaker: But if we check them at three months or six months, we would probably see a different picture, maybe more PTSD.
Speaker: And then cognitively, doing some kind of cognitive assessment so that you can encourage patients not to make bad decisions with their current functioning, I think is quite important.
Speaker: And I'm not sure that it has to be very in-depth because, again, a lot of this cognitive impairment, some of it will improve over time.
Speaker: But interestingly, we've seen a couple of patients who self-referred to our clinic after be ing in the ICU a long time ago, even 10 years ago.
Speaker: and did not have any post-ICU care, per se.
Speaker: And they come in and, you know, we have – sometimes we just do have Jim Jackson see these patients because the neuropsych issues are more prominent.
Speaker: But we had one man who was accidentally scheduled for the whole nine yards, and he had the pharmacist evaluation and the nurse practitioner visit and the cognitive eval.
Speaker: It was really disheartening to see how similar his problems were to somebody who is just getting out of the hospital.
Speaker: The difference was that he got out of the hospital, he went back to work three weeks after discharge, he struggled in his job, which was a high-level financial position, and eventually lost his job, never regained his previous level of physical functioning, was on a ton of meds,
Speaker: to help him sleep and to help him wake up and to this and all kind of trying to address the problems of post ICU syndrome.
Speaker: And 10 years have passed without any improvement.
Speaker: So on the one hand, that's very sad.
Speaker: On the other hand, that's very motivating to help us try to get to patients at a time point when we might be able to intervene on some of these recovery trajectories.
Speaker: And as far as we can tell, that requires seeing them as early as possible.
Speaker: We aim to see patients
Speaker: two weeks after hospital discharge, but we succeed on average about four weeks after hospital discharge.
Speaker: And let me ask you, so if I were a patient at Vanderbilt at your practice right now in the ICU, when I'm ready to get discharged, would I just basically be told we have this clinic, come to the clinic in two to four weeks?
Speaker: Do you screen people at that point?
Speaker: I mean, you did mention the six-minute walk, but are you doing testing on discharge?
Speaker: Are you tagging patients?
Speaker: as they leave the ICU as high risk?
Speaker: I'm just curious in terms of how exactly would it look if I were the patient?
Speaker: Yes.
Speaker: So we do tag them as high risk.
Speaker: We put them on the list, so to speak, while they're in the ICU.
Speaker: And of those patients who we think will be good candidates for the clinic, meaning that we think that they have a chance to return to baseline and be discharged from the hospital, about 20%
Speaker: will not survive the hospitalization.
Speaker: And when those that do survive, when they leave the hospital, we say, yes, come back and here's your clinic appointment.
Speaker: As advised by some of our former patients, they said, you know, you should not make this optional because patients don't know what they don't know.
Speaker: You tell them this is a mandatory part of their recovery so that they'll show up because in many cases they lack the insight into their disabilities.
Speaker: to voluntarily come to a clinic.
Speaker: So we try to make it seem like a normal part of their care.
Speaker: That being said, a number of them will still not come to clinic for a variety of reasons.
Speaker: They are cognitively impaired and they're weak and they can't drive for the most part, so they need a lot of help, and those are a lot of barriers to overcome.
Speaker: There's still a lot we don't know about what the unmet needs are in that post-discharge period.
Speaker: And we actually have just embarked on another study called Assessing Post-Intensive Care Syndrome together with Intermountain and Johns Hopkins and the VA in Salt Lake and Beth Israel to
Speaker: look at exactly that population, patients who are critically ill but we expect to discharge to home, not go to a rehab or an LTCH, and what are those needs in the post-ICU period?
Speaker: What are people not getting?
Speaker: Are they getting what we think that they were prescribed at discharge, and how can we intervene to try to reduce some of the sequelae of being in the ICU, including early readmission, which is a big problem?
Speaker: One of the things that you mentioned earlier, which obviously is no news to our audience, is the fragmentation of care and how that impacts patients.
Speaker: I was wondering, Carla, are you doing anything special with those patients that don't leave, don't go home, but might be going to an LTAC or going to a rehab in terms of flagging them or including this information as part of their discharge summary?
Speaker: Because I think that
Speaker: That's one of the things that I always wonder with delirium.
Speaker: We treat delirium, we talk about it in the ICU, and then they go to the floor, and a lot of times there's a big voltage drop, and nobody's really aware that grandma needs her glasses and her hearing aids, right, all the time, or she will get confused.
Speaker: And how do you manage those transitions of care with this population?
Speaker: Yeah, it's really tricky.
Speaker: At our center, you might go to the floor, or you'll go to...
Speaker: inpatient rehab or LTCH, if you go anywhere other than the floor, that is outside our system.
Speaker: So it's hard to reach those patients and their family members.
Speaker: So the first thing that we do is make sure that we have, like, three contact numbers for everybody.
Speaker: I was really shocked when we started the clinic that we were just not able to reach people a lot of times because they were so debilitated that even if they went, you know, home in quotation marks, they were not at home.
Speaker: They were staying with family.
Speaker: They were, you know, couch surfing.
Speaker: They were – their girlfriend broke up with them, so they were in somebody else's apartment.
Speaker: And not only could we not find them, but Home Health couldn't find them with their IV antibiotics and PT, OT couldn't find them.
Speaker: So contact information is key.
Speaker: We also started –
Speaker: Visiting the patients.
Speaker: So a lot of our patients, when they leave the ICU, are still pretty sick, and some may still be delirious.
Speaker: So we try to make a visit on the floor before they leave the hospital, and we give them a little brochure that has some information about post-ICU syndrome and some of the things they might run into.
Speaker: And if they do run into those things, to call us, that we can help them.
Speaker: To give them some sort of written information and wherever possible, talk to the families
Speaker: because if they are going to come to the clinic, it's the families who are going to drive them there to make sure that we sort of have the whole unit on board and make that personal contact at the point of, you know, before they actually leave our facility.
Speaker: But it is difficult when patients go to inpatient rehab or to an LTCH or to a skilled nursing facility.
Speaker: We try to guesstimate when they might be out of there and schedule an appointment just to have it on their discharge paperwork.
Speaker: But it's often a challenge to try to reach them after that point.
Speaker: And one of the things that I'm always interested as an internist at heart, obviously, is differential diagnosis.
Speaker: So we're talking about how we diagnose, we're talking about the syndrome, and that's not very specifically defined.
Speaker: But there clearly are some organic causes that might cause some of these dysfunctions.
Speaker: Any comments on some of the things that we should be thinking about that could be or sharing with our primary care physicians and colleagues of things that might mimic PICS but might have an organic cause that can be treated differently?
Speaker: Yeah, so, I mean, I think, you know, these patients, for the most part, did not have these problems before they had the, you know, chemical imbalances that either illness or we induced in their bodies and their brains.
Speaker: But you're right, you know, PICS is not protective against other things.
Speaker: I think having some ability to follow patients longitudinally, which a primary care physician would be doing, is going to be your best solution.
Speaker: strategy for figuring out what is normal PICS and what is something else.
Speaker: What we try to do, we see most of, you know, we're intensivists, so we're not interested in taking over primary care from somebody, but we see patients for one or two visits just to tie up the loose ends of things that are clearly critical care related.
Speaker: So, you know, for us, if you have a
Speaker: quote, temporary IVC filter or trach or line.
Speaker: So those things clearly need to be addressed.
Speaker: We do a fair amount of wound care and telling people that their hair and their nails will grow back, which they find very disturbing.
Speaker: But once we get all those things tied up, then we send a letter to the primary care physician if they have one.
Speaker: And if they don't have one, we try to get them one.
Speaker: saying, you know, this was the critical illness, which is already more than most primary care physicians get, right?
Speaker: This is what went down in the ICU.
Speaker: These are the problems that we identified as being related to the ICU.
Speaker: This is what we think should be done about it.
Speaker: And that, you know, really gives the primary care physician a kind of signpost if something is out of the, you know, out of the realm of
Speaker: what we've described.
Speaker: But truly just seeing patients post-ICU, the more patients you see, the more you learn not only about what post-ICU syndrome is, but, you know, what we could be doing differently in the ICU to prevent these problems from happening.
Speaker: So to me, that's been the most gratifying part of seeing patients in post-ICU is to help us be better ICU doctors.
Speaker: And part of that is medical, part of that is system, and part of that is, I think, prognostication.
Speaker: So we do a lot of prognosticating, life and death prognosticating for families in the ICU, based almost exclusively on our experiences in the ICU.
Speaker: And, you know, that is not always correct.
Speaker: We are not the best prognosticators.
Speaker: and seeing patients after the ICU has really made me both more optimistic and more pessimistic in certain situations for recovery in patients that we just didn't see long enough to make a good prognostication about.
Speaker: Well, and I think that also a lot of been written about heuristics and the heuristic of availability, right?
Speaker: We tend to remember...
Speaker: these very vivid cases that might not be positive, but it's very hard to, without follow-up, to really objectively understand what happens to these patients.
Speaker: And I think that that information probably is something that you do gain as you see these patients after their ICU stay with more frequency.
Speaker: Now, is it...
Speaker: One of the things that I'm interested in, you talked about how you have started this clinic and what you do at Vanderbilt, but I also think that in a lot of smaller practices, the volume might not be there to have a clinic on a regular basis.
Speaker: How do you work with primary care physicians in your community to try to make care for these survivors better?
Speaker: Well, you know, I think the first thing is just being available, right?
Speaker: So, um,
Speaker: I have a colleague in Kentucky, Ashley Montgomery Yates, who runs a clinic, and she was sort of running it by herself for a long time.
Speaker: But every PCP, it seems like, in Kentucky had her cell phone number, and there was a lot of communication, direct communication between her and the primary care physicians in her community so that she was able to make that ICU knowledge available
Speaker: to her colleagues and their patients, even if, you know, a clinic appointment was not in the cards.
Speaker: And so, you know, providing awareness, and I think the Society of Critical Care Medicine is trying to do this as well, you know, going to primary care conferences and trying to get the word out, like, this is a thing, you know, and if you need more information,
Speaker: it's out there to help you take care of these patients.
Speaker: Interestingly, there was a study in Germany that actually looked at it.
Speaker: So in Germany, most people have a primary care physician.
Speaker: It's a much more unified healthcare system.
Speaker: And what they did was train the specific primary care physician for each sepsis survivor in post-ICU syndrome, and they had a case management portion.
Speaker: And they didn't have a big outcome change in healthcare-related quality of life, which was the primary outcome.
Speaker: But the physical function actually did show a trend toward improvement, and I thought that was a really interesting approach since primary care physicians are providing the bulk of the post-ICU care.
Speaker: But there's also some good literature out there.
Speaker: Actually, one of my favorite articles about post-ICU syndrome
Speaker: appeared in the American Family Physician Journal, I think it was in 2009, which was a very succinct and good summary of here are the problems, here are the risk factors, here are the things that you can do, which I still refer to to this day.
Speaker: So the primary care physicians are certainly our partners in that.
Speaker: That being said, there are things that are obvious to us as intensivists
Speaker: you know, and this is where we kind of sell ourselves short as a subspecialty.
Speaker: We are subspecialty care, and we need to be available to provide that subspecialty opinion throughout the arc of recovery.
Speaker: So, you know, a surgeon might only want to operate, but they're not going to just say follow up with your PCP after you have a CABG, right?
Speaker: They're going to be available for the typical
Speaker: problems that might occur after a surgery.
Speaker: And I feel like we have a responsibility to either provide that care or set up a system where that knowledge is available to patients and families after the ICU, as well as other physicians.
Speaker: And when I'm a patient at your institution and I leave the ICU and I leave the hospital, will I get information about PICS?
Speaker: Is that something you're sharing with families and how do you do that?
Speaker: Yeah, we have a very homemade brochure that just says this is PICS and these are the kinds of problems you might have.
Speaker: And if you have them, we'd love to see you.
Speaker: And here's the number to call.
Speaker: Actually, we did a study that hopefully will be published soon looking at readmission risk in this population.
Speaker: And we provided as part of the study a 24-hour hotline that was staffed by our nurse practitioner intensive service.
Speaker: that patients could call 24 hours a day.
Speaker: They could call this number if they had problems after the ICU, and almost nobody called it.
Speaker: I think one of the fears as intensivists is that we will be overrun by ICU survivors asking for our advice, and that simply has not been our experience, even when we try to make it very easy for patients and families.
Speaker: But for the patients and families who are able to reach out, we should be available for them.
Speaker: What do you think is the next big thing or what's coming in the near future that excites you in this field, Carla?
Speaker: Well, one thing is, you know, as I mentioned, this population is kind of hard to reach, and coming back to the hospital is difficult for them on a number of fronts.
Speaker: We're starting a telehealth pilot that is trying to reach out to patients via telemedicine, and certainly with the new CMS rules, there seems to be some
Speaker: progress in the understanding and acceptability of telemedicine in reaching disadvantaged populations, so I'm hopeful about that.
Speaker: There have been some attempts to try to do some self-directed education and recovery training through, for example, smartphone apps, although, again, I think that these patients have enough problems with executive function
Speaker: and motivation that they need a structured program, at least in the beginning.
Speaker: Peer support is an area that's really had a lot of growth in the U.S. and abroad over the last couple of years, thanks in no small part to the peer support collaborative through SCCM.
Speaker: And more and more people are trying to offer that to patients.
Speaker: I think that's a big help for patients who are especially a little bit later in the
Speaker: recovery trajectory, and they're ready to talk about some of the issues that are still bothering them.
Speaker: In fact, we had, it's interesting, we had, this is why discharge paperwork is so important.
Speaker: We had a patient come in a couple weeks ago to clinic, and she, we were searching the chart, be like, who is this person?
Speaker: We haven't seen her recently.
Speaker: And it turned out that she had had a critical illness in 2012, which was the year we opened the clinic, and declined to come to clinic.
Speaker: at that time, but here she was, you know, all these years later, having troubles with sleeping and nightmares and some post-traumatic symptoms, and she pulled out her paperwork from her discharge all the way back then and saw her appointment and came back to clinic.
Speaker: So it may be never too late, you know, for some patients.
Speaker: But they might have different needs at different stages of recovery.
Speaker: Well, like they say, the best time to come to clinic was eight years ago.
Speaker: The second best time is today, right?
Speaker: Right.
Speaker: So a quick question in terms of this topic with families.
Speaker: Are there brochures available through the SCCM Collaborative that people can use at their hospitals to share this information so they have to reinvent the wheel with family members?
Speaker: Yes, there is a brochure that you can order, I think, in bulk, and we can get the link from SCCM.
Speaker: And they have some information on the website as well, including a soon-to-be updated referral list of existing post-ICU clinics and peer support groups that are active in the U.S. So if there's something near you, we are certainly happy to see patients
Speaker: from near and far, but we've had a couple of colleagues call us from other states and say, hey, this patient called me from Tennessee, and they were looking for post-ICU care, and we were just down the road.
Speaker: So I think there are some clinics out there where you can get some specialized care, and we want that referral info to be available to everybody.
Speaker: So we'll definitely include, I mean, the link to the SCCM website and other websites in the show notes.
Speaker: As we be respectful for your time, Carla, I think that we'd like to usually end the podcast with asking our guests some questions that tap into their wisdom that are not related maybe specifically to the topic that we discussed.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: So my first question is, what book of books have influenced you the most or what book have you gifted most often to others?
Speaker: Well, the book that I've really been excited about in recent times has been In Shock by Rena Adish, and we were so lucky to have her here at Vanderbilt a couple weeks ago, too.
Speaker: You know, I think she's an intensivist who herself sustained a critical illness, so has been able to really make a call to action from both sides of the fence there.
Speaker: It's a fantastic book for anybody, but especially for intensivists.
Speaker: It really gave me some additional understanding of critical care from the standpoint of a physician as well as the patient.
Speaker: I really loved it a lot.
Speaker: Sorry to interrupt.
Speaker: I did not read this book, but we definitely put it in the show notes.
Speaker: But if I recall correctly, she's an intensivist who had a postpartum complication, and she wrote a piece at the New England Journal of Medicine.
Speaker: Is that the same person?
Speaker: She did write a piece.
Speaker: She wrote a whole book about her experience, but excerpts did appear in some other publications.
Speaker: And she's back to practicing intensive care, which is fantastic.
Speaker: So we'll definitely include that in our show notes.
Speaker: So my second question is, what do you believe to be true in medicine or life that most other people don't believe?
Speaker: Well, this has really changed for me over the years of my practice.
Speaker: I think when you're in training, you tend to have a very pessimistic view of some of the patients' illnesses that we see in the ICU.
Speaker: And through seeing patients in the post-ICU clinic, including a couple who I straight told their families would not make it,
Speaker: It's very, very humbling to see somebody survive against all these odds.
Speaker: And so I just have to emphasize that prognostication is not a science, and the more we look at the whole trajectory of recovery after critical illness, the better we'll be able to take care of patients in the ICU.
Speaker: It's not a natural experiment when we are affecting the outcomes by limiting
Speaker: life support.
Speaker: Certainly, there are plenty of instances where we do that appropriately, but I think there are a lot more gray areas that we don't give ourselves or our patients credit for, and we just need to learn more about that.
Speaker: Yeah, and I think having a healthy dose of humility and understanding that what we think to be true today might be proven otherwise over time, and just being able to accept that, I think,
Speaker: on a regular basis is very important in our practice.
Speaker: I agree 100%.
Speaker: So true.
Speaker: So the last question for our closing question is, what would you want every intensivist who's listening to this podcast, every provider to know?
Speaker: Could be a quote or a fact or just a comment.
Speaker: Well, one of my favorite quotes is also the motto of the medical school here, which is the well-known aphroism from Hippocrates.
Speaker: life is short, the art long or something like that.
Speaker: I'm probably misquoting.
Speaker: But the second stanza reads, the physician must not only be prepared to do what is right himself, but also to make the patient, the attendants and externals cooperate.
Speaker: And, you know, that's not always easy to do in modern health care, but it's the job we agreed to do.
Speaker: And I think as we become more and more specialized in
Speaker: Intensive care in all aspects of medicine, taking that responsibility for systems, even though it's hard work, and building systems that get the right care to the right patient at the right time is our responsibility.
Speaker: And I think that it's a great place to end the conversation, especially in a world where we talk so much about physician burnout.
Speaker: Being able to always go back to first principles and remember why we started doing this, I think, is a good antidote for that situation as well.
Speaker: Absolutely.
Speaker: Well, Carla, it's been a delight to talk with you about this fascinating topic.
Speaker: I'm sure that as we learn more, we would love to have you back on the podcast and teach us what's new in the future.
Speaker: So again, thank you so much for your time and for sharing your knowledge with our audience.
Speaker: Thank you.
Speaker: Thanks again for listening to Critical Matters.
Speaker: Make sure to subscribe to this podcast on iTunes or Google Play.
