Brett, SJ

Meyer, J

Waldmann, C

Intensive Care Medicine

English

Spiral - Imperial College Digital Repository

"Should	ICU	clinicians	follow	patients	after	ICU	discharge?"	Joel	Meyer,	Stephen	Brett	and	Carl	Waldmann.		The	trajectory	of	recovery	from	critical	illness	is	often	portrayed	as	a	continuum.	At	one	extremity	lies	an	unstable	patient	dependent	on	life-sustaining	treatments	in	the	intensive	care	unit.	At	the	other	extremity	stands	an	independent	community-dwelling	individual	with	restored	personal,	social	and	cultural	wellbeing.	A	progressive	transition	from	illness	to	recovery	reflected	by	gradual	de-intensification	of	healthcare	occurs	over	many	weeks	to	months.	This	notion	of	a	continuous	arc	of	recovery	is	reflected	poorly	in	the	design	of	modern	healthcare	systems.	Patients	with	similar	care	needs	tend	to	be	co-located	for	operational	and	economic	reasons.	This	creates	arbitrary	institutional	and	professional	boundaries	which	transect	the	care	pathway.	Transitions	between	intensive	care,	high	dependency,	ward	and	home	are	often	fragmented,	leading	to	loss	of	information,	omissions	in	treatment	and	poor	patient	and	family	experience	(Reference	1,2)	.	The	challenge	of	addressing	fragmented	care	after	ICU	is	epitomised	at	the	crucial	point	of	discharge	home	from	hospital.	Hospital	clinicians	perceive	the	moment	of	discharge	home	as	a	long	anticipated	goal	marking	near	completion	of	clinical	recovery.	This	fallacious	mind-set	is	perpetuated	during	the	hospital	stay,	generating	unrealistic	expectations	of	patients	and	caregivers	about	life	at	home.	Passive	transfer	of	clinical	responsibility	occurs	via	a	written	discharge	document.	As	the	notional	separation	between	ICU	and	present	day	widens,	so	providers’	familiarity	with	ICU-related	interventions	(and	their	complications)	diminishes	(Reference	3).	This	impacts	on	medication	management,	follow	up	investigations,	specialist	review	and	prompt	referral	to	rehabilitation	services.	For	many	ICU	survivors	release	from	hospital	marks	the	start	of	an	arduous	struggle.	Persistent	physical,	psychological	and	cognitive	deficits	arising	from	critical	illness	are	highly	prevalent	(Reference	4).	Patients	and	families	lack	understanding	and	context	of	their	critical	illness;	resources	to	assist	with	life	at	home;	and	information	about	what	recovery	can	be	expected	to	involve	(Reference	5).Pre-existing	conditions	may	have	been	undertreated	before	admission	or	may	interact	to	compound	the	complexity	of	care	and	deepen	unmet	need.		Another	reality	is	that	many	patients	will	not	make	a	full	recovery	following	their	critical	illness.	However	deficits	that	cannot	be	reversed	ought	still	to	be	identified,	explained,	reconciled.	Resources	can	then	be	directed	to	adjusting	to	and	coping	with	diminished	quality	of	life	after	critical	illness.	This	requires	a	patient-	and	family-centred	approach	extending	beyond	ICU	and	into	the	adaptive	phase	of	recovery,	enabling	individuals	to	accomplish	what	matters	most	to	them	on	a	personal,	social	and	economic	level.			What	is	the	relevance	of	post	critical	care	follow-up	services	in	this	challenging	landscape?	The	last	20	years	represent	a	dynamic	period	of	multidisciplinary	engagement	with	critical	care	survivors,	moving	beyond	matters	of	life	and	death,	and	discovering	the	extent	of	their	previously	overlooked	morbidity.	The	most	prevalent	service	model	for	delivering	follow-up	is	the	outpatient	clinic.	To	our	knowledge	the	only	conventionally	designed	trial	of	the	post-ICU	“clinic”	concept	is	the	PRaCTICaL	study.	In	this	well	conducted	study	it	was	not	possible	to	identify	either	a	patient-centred	or	health	economic	benefit.	However,	only	one-	possibly	limited-	clinic	model	was	tested;	arguably,	the	quantitative	outcome	measures	may	have	been	insensitive	to	change.		More	recently	we	have	learned	how	challenging	demonstrating	change	can	be	(Reference	6).		Of	interest,	the	PIX	study	of	a	targeted	exercise	programme	failed	to	shift	a	physiological	outcome	measure,	yet	a	parallel	qualitative	evaluation	demonstrated	clear	value	for	those	in	the	intervention	arm;	patients	felt	more	motivated,	engaged	and	supported	(Reference	7).	This	disparity	between	quantitative	and	qualitative	findings	is	echoed	in	the	RECOVER	study	that	tested	a	greater	level	of	rehabilitation	support	within	hospital;	the	quantitative	analysis	failed	to	identify	a	measurable	change,	but	the	parallel	qualitative	analysis	showed	benefits	(Reference	8).											Fundamental	hurdles	including	heterogeneity	of	case-mix,	lack	of	blinding,	difficulty	measuring	the	dose	or	magic	bullet	of	a	complex	intervention,	and	incomplete	knowledge	about	the	outcome	measures	of	interest	may	hamper	comparative	effectiveness	trials	in	this	field.	Yet	it	is	widely	accepted	and	intuitive	that	follow-up	activity	is	an	effective	intervention.	The	majority,	88%,	of	UK	ICU	clinicians	surveyed	on	this	topic	cited	financial	constraints	as	the	main	barrier	to	ICU	follow	up	whereas	only	24%	cited	lack	of	current	evidence	for	benefit	and	only	12%	cited	lack	of	clinical	need	(Reference	9)	This	implies	a	determination	by	frontline	critical	care	staff	to	deliver	follow	up	services	in	spite	of	the	recognised	barriers.		The	failure	to	demonstrate	change	in	predominantly	single	intervention	studies	emphasises	the	need	to	develop	and	evaluate	future	projects	as	complex	interventions:	the	RECOVER	investigators	adopted	such	an	approach,	although	they	were	ultimately	unable	to	show	a	benefit	on	their	primary	outcome	measure	(Reference	10).		Post	ICU	follow	up	services	and	associated	programmes	to	enhance	post	ICU	health	are	increasingly	prevalent	in	the	UK	and	globally.	As	of	September	2017	the	UK’s	National	Institute	for	Health	and	Care	Excellence	(NICE)	recommends	healthcare	commissioners	ensure	services	they	fund	assess	and	provide	a	rehabilitation	plan	for	survivors	of	critical	illness	(Reference	11):-	"Commissioners	(clinical	commissioning	groups)	ensure	that	they	commission	services	that	follow	up	adults	who	were	in	critical	care	for	more	than	4	days	and	at	risk	of	morbidity	with	a	review	2	to	3	months	after	discharge	from	critical	care.	They	also	ensure	that	services	accept	and	reassess	all	adults	who	have	had	a	critical	care	stay	if	they	self-refer	at	any	time	after	discharge."	Emerging	concepts	in	recovery	and	rehabilitation	are	casting	doubt	on	the	relevance	of	a	one-size-fits-all	approach	to	follow-up	(Reference	12).	Recent	observational	data	highlight	the	interaction	between	pre-existing	conditions	and	post	critical	illness	health	trajectories	(Reference	13).		Tailored	interventions	may	be	needed	for	distinct	post-critical	illness	subtypes	(Reference	14).	Mind	and	body	‘cross-training’	could	provide	a	mechanism	for	the	observation	that	cognitive	rehabilitation	can	positively	impact	physical	outcomes,	and	vice-versa.	It	is	postulated	that	post	traumatic	growth	may	have	a	protective	role	in	long	term	outcomes	after	life	changing	illness	to	be	harnessed	in	the	post	critical	care	setting	(Reference	15).	Personal	characteristics	such	as	resilience,	coping,	and	acceptance	are	relevant	to	health-related	quality	of	life	and	may	be	modifiable	through	post	ICU	interventions	(Reference	16).		The	US	Society	of	Critical	Care	Medicine	Thrive	Post	ICU	Collaborative	was	convened	in	2017	to	foster	an	international	network	of	hospitals	focussed	on	exploring	diverse	models	of	follow	up.	One	such	model	is	the	innovative	In:SPIRE	(Intensive	Care	Recovery:	Supporting	and	Promoting	Independence	and	Return	to	Employment)	project	evaluating	a	5-week	post-ICU	rehabilitation	intervention	in	several	centres	in	Scotland	(Reference	17).	Candidate	follow	up	models	tend	to	be	intensive	care	practitioner-delivered	and	patient	co-designed	clinics	straddling	traditional	healthcare	boundaries.	Arguably	these	will	be	the	attributes	necessary	to	achieve	patient-centred,	cost-effective	and	integrated	ICU	follow	up	care	which	improves	long	term	outcomes	and	successfully	mirrors	the	continuum	of	recovery	from	critical	illness.					Idea	for	a	table/figure…	for	discussion/review	Follow	up	after	ICU	discharge	has	benefits	for…	The	patient	 The	family	 The	ICU	staff	 The	organisation/provider	The	GP	 The	economy/public	health	Research	Safety	netting	&	coordination	of	ongoing	care…address	omissions	in	care/FU	(Follow-Up)/meds		Provide	information/knowledge		Contextualisation	of	life	event		Improve	HRQOL	(Health	Related	Quality	of	Life)		Signpost	to	social	and	welfare	benefits		Provide	understanding	and	information		Signpost	to	resources	and	support		Expression	of	gratitude	&	emotional	link	to	the	unit	Realignment	of	purpose		Contextualisation	of	daily	efforts		Reduce	burnout/disillusionment		Learn	improve	humanise	care	Achieve	NICE	83	and	quality	standard	and	GPICS	(Guidelines	for	the	provision	of	Inte	nsive	Care	services)	recommendations		Improve	pt	and	family	experience		Quality	agenda		Patient	&	family	centred	care		Improve	ability	to	provide	post	ICU	care	through	info/support	Reduced	reattendance/readmission	to	hospital	and	use	of	emergency	services		More	return	to	independence		More	return	to	work/gainful	employment		Reduce	carer	burden	Provides	an	environment	in	which	to	study	survivorship/outcomes	and	recruit	to	studies									REFERENCES	1. 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Should ICU clinicians follow patients after ICU discharge? Yes

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Should ICU clinicians follow patients after ICU discharge? Yes

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