Intensive Care Unit Follow-up Clinic Research Articles

Using augmented intelligence to improve long term outcomes.

For augmented intelligence (AI) tools to realize their potential, critical care clinicians must ensure they are designed to improve long-term outcomes. This overview is intended to align professionals with the state-of-the art of AI. Many AI tools are undergoing preliminary assessment of their ability to support the care of survivors and their caregivers at multiple time points after intensive care unit (ICU) discharge. The domains being studied include early identification of deterioration (physiological, mental), management of impaired physical functioning, pain, sleep and sexual dysfunction, improving nutrition and communication, and screening and treatment of cognitive impairment and mental health disorders.Several technologies are already being marketed and many more are in various stages of development. These technologies mostly still require clinical trials outcome testing. However, lacking a formal regulatory approval process, some are already in use. Plans for long-term management of ICU survivors must account for the development of a holistic follow-up system that incorporates AI across multiple platforms. A tiered post-ICU screening program may be established wherein AI tools managed by ICU follow-up clinics provide appropriate assistance without human intervention in cases with less pathology and refer severe cases to expert treatment.

Intensive care unit follow-up clinic activities: a scoping review.

The importance of ongoing post-discharge follow-up to prevent functional impairment in patients discharged from intensive care units (ICUs) is being increasingly recognized. Therefore, we conducted a scoping review, which included existing ICU follow-up clinic methodologies using the CENTRAL, MEDLINE, and CINAHL databases from their inception to December 2022. Data were examined for country or region, outpatient name, location, opening days, lead profession, eligible patients, timing of the follow-up, and assessment tools. Twelve studies were included in our review. The results obtained revealed that the methods employed by ICU follow-up clinics varied among countries and regions. The names of outpatient follow-up clinics also varied; however, all were located within the facility. These clinics were mainly physician or nurse led; however, pharmacists, physical therapists, neuropsychologists, and social workers were also involved. Some clinics were limited to critically ill patients with sepsis or those requiring ventilation. Ten studies reported the first outpatient visit 1-3months after discharge. All studies assessed physical function, cognitive function, mental health, and the health-related quality of life. This scoping review revealed that an optimal operating format for ICU follow-up clinics needs to be established according to the categories of critically ill patients.

The feasibility and acceptability of a physician-led ICU follow-up service: A prospective cohort study

BackgroundIncreased recognition of post–intensive care syndrome has led to widespread development of intensive care follow-up services internationally. ObjectiveThe objective of this study was to determine the feasibility and acceptability of an intensive care unit (ICU) follow-up clinic in Australia for patients and their caregivers and to describe satisfaction with this service. MethodsThis was a prospective cohort study in a mixed tertiary ICU in Australia. Eligible patients were adults admitted to the ICU for 7 days or more and/or ventilated for 48 h or more, as well as their primary caregiver. Patients and their primary caregivers were invited to attend a follow-up clinic 4–8 weeks after hospital discharge. The clinic appointment was attended by an ICU physician and nurse, with multidisciplinary support. Feasibility and acceptability were defined as the proportion of clinic attendance and frequency of interventions initiated at the clinic. Satisfaction was measured by a 5-point satisfaction survey (very dissatisfied to very satisfied). The burden of ongoing disease was reported via multiple validated instruments. ResultsFrom April 2020–July 2021, 386 patients met the inclusion criteria. Only 146 patients were approached for consent due to site staffing limitations. Eighty-three patients and 32 caregivers consented to attend the clinic. Seventy percent (54/77) of patients attended scheduled appointments and 50% (16/32) of caregivers. For patients, 23 medical referrals were made, 8 patients had medication changes, and 10 patients were offered social work support. Satisfaction surveys were completed by 65% (35/54) of attending patients; 97% (34) patients reported either being ‘very satisfied’ or ‘satisfied’ with the service. All responding caregivers (10) were either ‘very satisfied’ or ‘satisfied’ with the clinic. ConclusionThere were a large number of patients meeting the inclusion criteria to the ICU follow-up clinic, and clinic attendance was moderate for patients but lower for caregivers. Reported satisfaction with the service was high for both patients and their caregiver.

Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): feasibility of a pragmatic randomised controlled trial

BackgroundICU survivors often suffer from prolonged physical and mental impairments resulting in the so called “Post-Intensive Care Syndrome” (PICS). The aftercare of former ICU patients affected by PICS in particular has not been addressed sufficiently in Germany so far. The aim of this study was to evaluate the feasibility of a pragmatic randomised trial (RCT) comparing an intensive care unit (ICU) follow-up clinic intervention to usual care.MethodsThis pilot study in a German university hospital evaluated the feasibility of a pragmatic RCT. Patients were assigned in a 1:1 ratio to an ICU follow-up clinic intervention or to usual care. The concept of this follow-up clinic was previously developed in a participatory process with patients, next of kin, health care professionals and researchers. We performed a process evaluation and determined acceptability, fidelity, completeness of measurement instruments and practicality as feasibility outcomes. The RCT’s primary outcome (health-related quality of life) was assessed six months after ICU discharge by means of the physical component scale of the Short-Form-12 self-report questionnaire.ResultsThe pilot study was conducted from June 2020 to May 2021 with 21 and 20 participants in the intervention and control group. Principal findings related to feasibility were 85% consent rate (N = 48), 62% fidelity rate, 34% attrition rate (N = 41) and 77% completeness of outcome measurements. The primary effectiveness outcome (health-related quality of life) could be measured in 93% of participants who completed the study (N = 27). The majority of participants (85%) needed assistance with follow-up questionnaires (practicality). Median length of ICU stay was 13 days and 85% (N = 41) received mechanical ventilation, median Sequential Organ Failure Assessment Score was nine. Six-month follow-up assessment was planned for all study participants and performed for 66% (N = 41) of the participants after 197 days (median).ConclusionThe participatory developed intervention of an ICU follow-up clinic and the pragmatic pilot RCT both seem to be feasible. We recommend to start a pragmatic RCT on the effectiveness of the ICU follow-up clinic.Trial registrationClinicalTrials.gov US NLM, NCT04186468, Submission: 02/12/2019, Registration: 04/12/2019, https://clinicaltrials.gov/ct2/show/NCT04186468

Effect of intensive care unit-specific virtual reality (ICU-VR) to improve psychological well-being in ICU survivors: study protocol for an international, multicentre, randomised controlled trial—the HORIZON-IC study

IntroductionA substantial proportion of intensive care unit (ICU) survivors develop psychological impairments after ICU treatment, part of the postintensive care syndrome, resulting in a decreased quality of life. Recent data...

Meeting the Challenges of Establishing Intensive Care Unit Follow-up Clinics.

Intensive care unit follow-up clinics are becoming an increasingly widespread intervention to facilitate the physical, cognitive, psychiatric, and social rehabilitation of survivors of critical illness who have post-intensive care syndrome. Developing and sustaining intensive care unit follow-up clinics can pose significant challenges, and clinics need to be tailored to the physical, personnel, and financial resources available at a given institution. Although no standard recipe guarantees a successful intensive care unit aftercare program, emerging clinics will need to address a common set of hurdles, including securing an adequate space; assembling an invested, multidisciplinary staff; procuring the necessary financial, information technology, and physical stuff; using the proper screening tools to identify patients most likely to benefit and to accurately identify disabilities during the visit; and selling it to colleagues, hospital administrators, and the community at large.

Prevalence of post-intensive care syndrome in mechanically ventilated patients with COVID-19

Coronavirus disease 19 (COVID-19) patients usually require long periods of mechanical ventilation and sedation, which added to steroid therapy, favours a predisposition to the development of delirium and subsequent mental health disorders, as well as physical and respiratory sequelae. The aim of this study was to determine the prevalence of post-intensive care syndrome (PICS) at 3 months after hospital discharge, in a cohort of mechanically ventilated patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). An ambispective, observational study was conducted in three hospitals with intensive care unit (ICU) follow-up clinics. We studied adults who survived a critical illness due to SARS-CoV-2 infection requiring invasive mechanical ventilation. A physical (muscle strength and pulmonary function), functional [12-Item Short Form Health Survey (SF-12), and Barthel score], psychological [hospital anxiety and depression (HADS) and posttraumatic stress disorder symptom severity scales], and cognitive [Montreal cognitive assessment (MoCA) test] assessment were performed. A total of 186 patients were evaluated at 88 days (IQR 68–121) after hospital discharge. Mean age was 59 ± 12 years old, 126 (68%) patients were men, and median length of mechanical ventilation was 14 days (IQR 8–31). About 3 out of 4 patients (n = 139, 75%) met PICS criteria. Symptoms of cognitive and psychiatric disorders were found in 59 (32%) and 58 (31%) patients, respectively. Ninety-one (49%) patients had muscle weakness. Pulmonary function tests in patients with no respiratory comorbidities showed a normal pattern in 93 (50%) patients, and a restrictive disorder in 62 (33%) patients. Also, 69 patients (37%) were on sick leave, while 32 (17%) had resumed work at the time of assessment. In conclusion, survivors of critical illness due to SARS-CoV-2 infection requiring mechanical ventilation have a high prevalence of PICS. Physical domain is the most frequently damaged, followed by cognitive and psychiatric disorders. ICU follow-up clinics enable the assistance of this vulnerable population.

Posttraumatic stress phenomena in critical illness and intensive care survivors

The intensive care unit (ICU) within a hospital is typically thought of as a place for the provision of patient care for a life-threatening emergency. Less frequently do we consider it an integral part of disaster response. The COVID-19 pandemic is a public health disaster that has caused surges of critically ill patients requiring treatment in intensive care units (ICUs). However, it is important to bear in mind that survival of a critical illness can come at a cost, including to mental health. Being critically ill and requiring life-saving treatments is extremely stressful, and survivors frequently have substantial decrements in physical functioning, cognition, and emotional health. Remarkably, one in five critical illness survivors has clinically significant symptoms of posttraumatic stress disorder (PTSD). Risk factors, or markers of risk, include prior anxiety and depression, high doses of sedative medications in the intensive care unit (ICU), memories of nightmare-like experiences in the ICU, and emotional distress in early recovery. As with PTSD in other contexts, social support is a protective factor. ICU follow-up clinics, in-ICU psychological interventions, ICU diaries, post-ICU telephonic and computer-based cognitive-behavioral interventions, and virtual reality interventions all show promise in preventing long-term PTSD in critical illness survivors, perhaps particularly in those with substantial emotional distress in early recovery. However, awareness regarding this problem is still growing, as are changes to post-ICU care delivery. Hopefully, improved awareness on the part of the psychiatric community will help with recovery from the COVID-19 pandemic disaster.

Experiences, opinions and expectations of health care providers towards an intensive care unit follow-up clinic: Qualitative study and online survey

ObjectivesIndependent of the underlying disease, intensive care unit survivors often suffer from cognitive, physical and mental impairments, also known as post-intensive care syndrome (PICS). Specific follow-up services are recommended for these patients. This study aims to capture the perspectives of health care providers on the development of the first intensive care unit follow-up-clinic in Germany. Research methodologyA qualitative study with six focus groups (n = 41) and six expert interviews, followed by a quantitative survey was conducted, involving nine different professions. Qualitative and quantitative data were analysed using thematic analysis and descriptive statistics, respectively. FindingsParticipants described aftercare of former intensive care unit patients as complex and appreciated the idea of an intensive care unit follow-up clinic to improve continuity of care and multidisciplinary collaboration. The favoured model combined diagnostics and targeted referral of patients to specialists and therapists with the provision of information. In the survey, participants disagreed on how to implement this referral system but agreed that assessments should be multidimensional. ConclusionThe necessity of and important criteria for the design of an intensive care unit follow-up clinic were identified. We will integrate these data with further evidence to develop a concept for a complex intervention.

Ten minutes with Dr Andy Georgiou, Director of Intensive Care, and Margi Jenkins, Matron for Intensive Care and Outreach at The Royal United Hospitals NHS Trust, Bath, UK

Photograph: R Howman. ### Biography Andy Georgiou has been the director of the Intensive Care Unit at the Royal United Hospital in Bath since 2013 and is an honorary senior...

Lessons learnt during the implementation of a web-based triage tool for Dutch intensive care follow-up clinics

ObjectivesScreening for symptoms of postintensive care syndrome is based on a long list of questionnaires, filled out by the intensive care unit (ICU) survivor and manually reviewed by the health...

Neurodevelopmental Outcomes in 22 Children With Microcephaly of Different Etiologies.

We examined longitudinal neurodevelopmental outcomes in a series of infants with microcephaly. Retrospective review identified neonatal intensive care unit follow-up clinic patients with a diagnostic code of microcephaly, verified by head circumference less than the fifth precentile (WHO growth curves). Data were collected regarding clinical history and developmental assessments by Capute Scales and gross motor age equivalent. Developmental Quotient (DQ) was age adjusted up until 2 years for preterm infants. Twenty-two infants had microcephaly. At latest follow-up (3-66 months, mean 27.2), 73% had delay (DQ < 70) in ≥1 area of development: gross motor 65% (mean DQ 56.8), visual-motor 59% (mean DQ 62.7), and language 59% (mean DQ 65.9). In this sample, postnatal onset and diagnosis of epilepsy were associated with lower DQs. We conclude that infants with microcephaly are at significant risk for delay across all aspects of development and for long-term disability. Postnatal etiologies of microcephaly and infants with comorbid epilepsy had worse outcomes.

Evaluation of disabilities and rehabilitation needs after critical illness: Impact of an intensive care unit follow-up clinic in the University Hospital of Angers

After critical illness, some survivors experience long-term physical, functional, neurocognitive and/or mental health impairments, which has been termed “Post–Intensive Care syndrome” (PICS) [1] . A specific follow-up is required and many specialized follow-up clinics have been created both abroad and in France. The aim of this study is to evaluate long-term outcomes after critical illness, through the International Classification of Functioning, Disability and Health, and to analyse rehabilitation needs after intensive care unit (ICU) discharge. Adult intensive care patients (> 18 years old), mechanically ventilated for 5 days or more, were recruited. They were examined one month after ICU discharge by a multidisciplinary team including an intensivist, a nurse, a psychiatrist and a physical medicine and rehabilitation (PM&R) physician. Functional assessment included an orthopedic and neuromuscular examination, a functional evaluation of the upper limbs, a gait and balance evaluation, a six-minute walk test and a cognitive outcomes’ study. Diagnoses and rehabilitation needs were analyzed. Since April 2015, 15 patients were enrolled in the ICU follow-up clinic. Eight patients were diagnosed with thirteen rehabilitation needs: 2 rotator cuff tendinopathies, 4 peripheral neuropathies, 1 central nervous system disorder, 1 severe cognitive impairment and 5 exercise intolerances. Ten rehabilitation prescriptions were made: 4 renewals, 4 new liberal prescriptions and 2 inpatient rehabilitations. Advice was provided to ten patients (to continue basic activities of daily living, to do regular physical activity or self-exercises, driving advice). The creation of an ICU follow-up clinic in University Hospital of Angers meets a health need by a personalized and comprehensive assessment of patients discharged from intensive care. This structure is functional and allows an adaptation of the management of long-term disabilities after critical illness.

Critical Care Follow-up Clinics

The purpose of this scoping review is to identify evidence describing benefits of interventions provided in intensive care unit (ICU) survivor follow-up clinics. Advances in ICU treatments have increased the number of survivors who require specialized care for ICU-related sequelae. Intensive care unit survivor follow-up clinics exist, yet little is known about the nature and impact of interventions provided in such clinics. A scoping review of publications about in-person post-ICU follow-up care was undertaken. Ten databases were searched yielding 111 relevant unique publication titles and abstracts. Sample heterogeneity supported using a scoping review method. After excluding nonrelated publications, 33 reports were fully reviewed. Twenty international publications were included that described ICU follow-up clinic interventions and/or outcomes. Authors discussed very diverse interventions in 15 publications, and 9 reported some level of intervention effectiveness. Evidence was strongest that supported the use of prospective diaries as an intervention to prevent or improve psychological symptoms, whereas evidence to support implementation of other interventions was weak. Although ICU follow-up clinics exist, evidence for interventions and effectiveness of treatments in these clinics remains underexplored. Intensive care unit survivor follow-up clinics provide a venue for further interdisciplinary intervention research that could lead to better health outcomes for ICU survivors.

A Clinic Model: Post-Intensive Care Syndrome and Post-Intensive Care Syndrome-Family.

The number of patients surviving critical illness in the United States has increased with advancements in medicine. Post-intensive care syndrome and post-intensive care syndrome-family are terms developed by the Society of Critical Care Medicine in order to address the cognitive, psychological, and physical sequelae emerging in patients and their families after discharge from the intensive care unit. In the United Kingdom and Europe, intensive care unit follow-up clinics have been used to address the complications of post-intensive care syndrome for some time. However, the interprofessional clinic at Vanderbilt University Medical Center is among the first in the United States to address the wide variety of problems experienced by intensive care survivors and to provide patients and their families with care after discharge from the intensive care unit.

Integrative review of nurse-led follow-up after discharge from the ICU.

To analyse and synthesise the structure, content, types of outcome variables and advantages of nurse-led follow-up of adult patients after discharge from intensive care units. Follow-up service after discharge from the intensive care unit has been suggested as a way of supporting recovery of patients. Nevertheless, varieties exist in the understanding and content of nurse-led follow-up. An integrative review of nurse-led follow-up inspired by the framework of Whittemore and Knafl. An integrative method merged with the recommendations of the PRISMA statement was used to structure the review and findings. Online databases PubMed, CINAHL, ScienceDirect and Scopus were searched from the years 2003-2014. The retrieved articles were independently assessed by two reviewers. Critical appraisal was conducted using check lists from Johanna Briggs Institute. Emerging patterns were validated by all the authors throughout the entire process of analysis. Seventeen papers were included. Three patterns of nurse-led follow-up were identified: (1) Ward visits--in the immediate time after discharge from intensive care unit, (2) Ward visits and appointment(s) to an intensive care unit follow-up clinic and (3) follow-up visit to an intensive care unit and phone call(s) after discharge. Content of short-term nurse-led follow-up (1) ranged from clinical assessment to supporting patients in articulating their subjective health concerns. Long-term nurse-led follow-up (2, 3) included appointments, phone call(s) or information on where advice could be sought. Types of outcome variables were primarily descriptive. There were strong implications for patients' satisfaction with nurse-led follow-up up to six months after discharge. Nurse-led follow-up might promote patients' health and enable use of adequate resources. The findings of this review could be used to design, and test, future interventions and their implementation.

Medication issues experienced by patients and carers after discharge from the intensive care unit

PurposeMedication-related problems (MRPs) frequently occur at the interfaces of care settings. We examined this further because little has been published about MRPs experienced by patients/carers after discharge from the intensive care unit (ICU). Methods and MaterialsMedication history data were collected before, during, and after ICU admission and by face-to-face semistructured interviews with 21 patients and 13 carers attending the ICU Follow-up Clinic (FC) of our 35-bed adult ICU. ResultsA total of 122 drugs were prescribed regularly before ICU admission, 168 on ICU discharge, 132 at hospital discharge, and 128 at the FC. Medication-related problems were identified with hypnotics/anxiolytics, antidepressants, proton pump inhibitors, and analgesics. Good follow-up was observed in all 4 cases where the antidysrhythmic agent amiodarone was initiated on ICU. Patients/carers described 20 cases of difficulty in obtaining appropriate and timely supplies and 19 of insufficient information. ConclusionsThese results show that our incidence of MRPs after ICU discharge was encouragingly infrequent, in which we attribute it to targeted medicine reconciliation and the availability of our FC. However, MRPs were perceived to stem from inadequate communication at the interfaces of care and the lack of opportunity for patients/carers to obtain relevant information. We recommend that FC should focus on MRPs during their consultation and that further research in this area should be performed to examine our observations further.

Physical and psychological sequelae of critical illness

To measure levels of anxiety, depression and post-traumatic stress among survivors of a critical illness and to relate these symptoms to general health parameters. A prospective study of patients who had spent a minimum 3 days (median 9 days) in a general intensive care unit (ICU). Of these patients, 51 were interviewed 3 months after discharge and 45 of them were reviewed at 9 months. General health was assessed by a physical symptom score, the EuroQol 'thermometer' and the Short Form 36 (SF-36) questionnaire. Physical and mental component summary measures (PCS, MCS) were calculated from the SF-36 data. Psychological health was assessed using both the Hospital Anxiety and Depression Scale and the Impact of Events Scale. At both 3 and 9 months after ICU discharge 24% of patients qualified as a 'case' of anxiety, while similar figures were seen for intrusion (24 and 20%). The incidence of depression (35 and 47%) and avoidance (36 and 38%) was higher on each occasion. Four of the eight SF-36 domains improved with time, as did PCS (from 29.0 to 35.4), but there was no significant difference in physical symptom score, EuroQol value or MCS. Strong correlations were seen between the physical and psychological parameters at each time point. A substantial proportion of patients who survive a critical illness show evidence of anxiety and depression up to 9 months later, and most of them also have symptoms indicative of post-traumatic stress. Delayed physical recovery may contribute to this psychological morbidity. ICU follow-up clinics should be able to detect patients suitable for psychological intervention.

A self-report-based study of the incidence and associations of sexual dysfunction in survivors of intensive care treatment

To determine the incidence and associations of sexual dysfunction in survivors of intensive care unit treatment in their first year after hospital discharge using a self-report measure. A prospective observational study. ICU Follow-up Clinic, The Royal Berkshire Hospital, Reading. One hundred and twenty-seven patients aged 18 years and over who spent 3 days or more in the intensive care unit. Demographic data; reported incidence of sexual dysfunction and post-traumatic stress disorder symptomatology; association between reported sexual dysfunction and age, gender, post-traumatic stress disorder symptomatology and length of intensive care unit stay; patient and partner satisfaction with current sex life. Fifty-two patients (43.6%) reported symptoms of sexual dysfunction. There was a significant association between sexual dysfunction and post-traumatic stress disorder symptomatology (p = 0.019). There was no association between reported sexual dysfunction and gender (p = 0.33), age (p = 0.8) or intensive care unit length of stay (p = 0.41). Forty-five per cent of patients and 40% of partners were not satisfied with their current sex life. No other medical practitioner had sought symptoms of sexual dysfunction during the study period. Symptoms of sexual dysfunction are common in patients recovering from critical illness and appear to be significantly associated with the presence of post-traumatic stress disorder symptomatology. The intensive care unit follow-up clinic is a suitable forum for the screening and referral of patients with sexual dysfunction.

Family-Centered Care

I read "The Principles for Family-Centered Neonatal Care" with great interest. As a physician who has worked in a state government-operated neonatal intensive care unit follow-up clinic, I agree wholeheartedly with the principle of open and honest communication between parents and professionals, especially regarding poor developmental outcomes. Unfortunately, physicians, despite their own feelings about this issue, may come under pressure from third parties to withhold certain information from families. In my own experiences, I have been drawn aside in private conversations and told that if I continue to tell parents that their child is mentally retarded or has cerebral palsy, it might have an adverse impact on my career.