Managing care for patients after an ICU stay has always been a challenging task facing hospitalists. COVID-19 has only added another layer of complexity, along with more patients.
Each year more than 5 million people are treated in U.S. ICUs, according to the Society of Critical Care Medicine. For those patients who recover sufficiently to reach the general floor, hospitalists play a critical role not only in providing the necessary inpatient care but also optimizing medication regimens and coordinating all the steps needed for a safe discharge that facilitates long-term recovery.
In the last decade, critical care clinicians and researchers have coined the term post-intensive care syndrome (PICS) to describe the constellation of lingering physical and mental health effects that patients can encounter after an ICU stay. If physicians and other clinicians intervene while patients are still in the hospital, the extent of these problems may be reduced for some patients, said Carla Sevin, MD, who directs the ICU Recovery Center at Vanderbilt University Medical Center in Nashville.
“The whole arc of recovery starts really in the ICU at the time that you're critically ill,” said Dr. Sevin, emphasizing that support ideally extends through discharge and beyond. “We not infrequently will have patients self-refer to our clinic who are a year or five years or 10 years out from their ICU stay and they kind of plateaued at three weeks posthospital and they've never really gotten any better.”
Post-ICU acute care
Although the pandemic has brought new attention to ICU care, the critical steps to helping ICU patients continue recovery after transfer to the general floor don't differ much by whether the diagnosis is COVID-19 or another medical condition, said Brad Butcher, MD, medical director of the Critical Illness Recovery Center at the University of Pittsburgh Medical Center.
It's important to get rehabilitation started for these patients as soon as possible, he said, “to keep them as close to their premorbid level of function as possible.” Along with physical and occupational therapy, other therapy services may need to be consulted, Dr. Butcher said. For instance, someone who was intubated for a long stretch might require speech therapy to help address swallowing difficulties.
The patient's med list should also be scrutinized, since some medications might need to be discontinued immediately while others may need a future stop date. On the other hand, it might be appropriate to restart some medications. For instance, a beta-blocker may have been halted during treatment for septic shock. “If you aren't being vigilant, that may never get restarted once their blood pressure normalizes,” Dr. Butcher said. Also review whether lines that were inserted in the ICU, including catheters and central lines, are still needed.
Depression, as well as anxiety and post-traumatic stress disorder (PTSD), are too often overlooked in hospitalized patients, both new incidence as well as worsening of symptoms, said Babar Khan, MBBS, medical director of the Eskenazi Health Critical Care Recovery Center in Indianapolis, which is affiliated with Indiana University.
About one-third of 204 ICU survivors from the center had untreated or inadequately treated depressive symptoms at their first visit there after hospitalization, according to a study Dr. Khan and colleagues published in 2017 in the Journal of Hospital Medicine.
These mental health symptoms “routinely get missed because we don't screen patients for those disorders when they come out of the ICU,” he said. “It mostly gets chalked up to, ‘Well, they're just getting over a severe illness, and it might be all situational.’”
Clinicians also should more routinely screen for cognitive changes in the hospital given how common those deficits are in ICU survivors. Dr. Khan pointed to another study, published in 2013 in the New England Journal of Medicine, that tracked cognition in 821 ICU survivors. By the end of the first year, one-third showed cognitive impairment similar to individuals with moderate traumatic brain injury, the researchers found.
Unless these cognitive issues are identified, ideally before discharge, patients may have difficulties that affect their health, such as keeping up with medications, Dr. Khan said. Or they may return to work and realize that they can't handle their jobs, which can lead to frustration and possibly other conditions, such as depression, he said.
In addition, the time in the hospital after an ICU stay can be a good opportunity to revisit end-of-life treatment wishes, Dr. Butcher said. “They might say, ‘You know what, I survived once in the ICU, there's no way I ever want to go back there.’”
Screening for mental health symptoms may be even more important for patients with COVID-19, Dr. Khan said. Treatment by doctors and nurses heavily garbed in personal protective equipment makes interaction and human comfort difficult, he said. “They're in complete isolation and then they are suffering from COVID, which makes them terrified to begin with.”
Dr. Butcher agreed. “There's a profound limitation on the ability for family members and loved ones to visit, which could theoretically heighten the psychological sequelae of PICS—the depression, the anxiety, and the PTSD.”
ACP Member Arwa Zakaria, DO, a Vanderbilt hospitalist, prefers to visit the ICU before a patient is transferred from there to her care. That way she can consult with the ICU team and assess the patient's mental status and respiration. The goal is to prevent a potential return to the ICU, which can occur if the patient's changing oxygen needs can't be handled on the general floor, she said.
Dr. Zakaria, who has been primarily treating COVID-19 since spring, also stressed the importance of remaining alert to the emergence of new medical issues in these patients. If a patient with COVID-19 spikes a fever, be sure to rule out other potential causes, such as a bloodstream or urinary tract infection, Dr. Zakaria said.
“These patients can have other multiple processes happening at the same time,” she said. “That's something that we're having to still keep our eyes and our mind open to understanding—that it's not just all related to the coronavirus.”
Hospitalists should also keep their minds and eyes open when planning discharge for those who have been in the ICU. A patient may not have a family doctor or may not be able to get a visit quickly after leaving the hospital, Dr. Sevin said. If the patients must continue some medications for longer than two weeks, consider discharging them with refill prescriptions.
Dr. Sevin and other critical care clinicians recently compiled a checklist, “The Dirty Dozen,” with broad guidance for preparing patients for discharge after mechanical ventilation. The list, posted April 22 on Life in the Fast Lane, an emergency medicine and critical care medical education blog, was created to assist physicians discharging COVID-19 patients, but its recommendations can be applied more broadly, she said.
Among some of the reminders related to common discharge errors are the following:
- What's the outpatient plan to monitor anticoagulation, including its duration, once the patient leaves the hospital? What key inpatient data are being handed off?
- Is there a list of what lines, tubes, and drains the patient had in the hospital, so those areas can be monitored for healing and infection risk?
- Does the patient know whom to contact if any health issues arise before that first primary care visit?
With patients who were critically ill with COVID-19, emotional aspects shouldn't be overlooked as they begin to recover, Dr. Zakaria said. They can be reassured that their recovery will continue, even if it's not as fast as they'd prefer, she said.
“It's talking to them about this ordeal,” she said. “A lot of the uncertainties, the anxieties, the angst of, ‘What if this is something that comes back? Or, what if I don't ever feel as good as I once did?’”
As part of the discharge process, Dr. Khan recommended that hospital physicians talk with caregivers, even if visiting restrictions limit that communication to phone or video. It's particularly important to set up a mini-family conference if the patient has experienced some cognitive changes, Dr. Khan said. Physicians can also educate caregivers about care coordinators, social workers, and others who can help after discharge, along with setting realistic expectations regarding their loved one, he said.
That way, he said, “the caregivers will understand what worrisome health symptoms they are looking for, and how their significant other has changed because of their stay in the intensive care unit.”
Through his work at the University of Pittsburgh's Critical Illness Recovery Center, Dr. Butcher has developed a better sense of how challenging some patients' lives can be after the ICU.
He recounted how some patients may struggle 10 minutes to button a shirt because of changes in fine motor skills. Others may describe going to the grocery store and not being able to remember how to navigate the aisles or muster enough strength to push the cart. “You just assume that they're going to go back [home] and their life will resume as normal,” Dr. Butcher said.
Post-ICU clinics designed to identify and intervene with such issues continue to be launched, though they remain rare. As of late summer, Dr. Sevin knew of nearly 30 clinics operating in the U.S. and others in the works.
Dr. Butcher, along with Drs. Khan and Sevin, were among the authors of a 2019 paper in Critical Care Medicine that explored barriers to opening these clinics, some of which were financial and logistical: lack of funding or space, practice variations between clinicians, and hospital billing infrastructure.
The financial reality is that these clinics don't generate revenue, Dr. Butcher said. But they can contribute to cost savings, such as by reducing hospital readmissions, he said. Both Drs. Butcher and Sevin noted an encouraging uptick in post-ICU clinics as hospitals endeavor to help a widening pool of COVID-19 survivors.
“They call them post-COVID clinics, but they are post-ICU clinics by another name,” Dr. Sevin said. “I'm hopeful that those will continue. There certainly have been few benefits to this global pandemic. But one of them one can argue has been that a light has been shone on the challenges of recovering from severe critical illness.”