Dr Mikkelsen: Over the last decade, we have come to recognize that long-term impairments in cognition, mental health, and physical function are common after critical illness; issues of survivorship are rarely addressed in the hospital or thereafter; and care coordination is often lacking for survivors, an important problem given how common post-acute care use is among these patients.
Dr Jutte: PICS is patient- or caregiver/family-support specific. Not everyone will experience each of these outcomes from critical illness, and the PICS phenotypes differ across individuals. PICS is a prime factor precipitating the growing need for early rehabilitation so that we can promote wellness among survivors and better prepare them for continued rehabilitation and recovery.
It is hypothesized that people with PICS phenotypes have unmet needs following hospitalization, including ineffective post-discharge follow-up care. We have limited data regarding post-hospitalization programs such as outpatient care for these patients and which elements or factors may be most beneficial.
Pulmonology Advisor: What are some of the most promising interventions for the different aspects of PICS?
Dr Jackson: I think those of us who treat and research PICS are encouraged by a variety of emerging interventions. Hospitals are increasingly using a bundled treatment approach known as the ABCDE Bundle (Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility), a focused, patient-centered approach to care that tries to anticipate and actively address issues such as problems with mobility, delirium, patient and family stress.6 This approach appears to be promising with respect to patient outcomes and clinicians, and entire healthcare systems are implementing it.
Support groups are also really catching on. They have not been studied with the rigor that they need to be, but early evidence suggest that patients with PICS — like so many other conditions — can benefit from the friendships, social bonds, and wisdom that like-minded people can impart to them.7 Cognitive rehabilitation of patients with cognitive impairment is also promising; a few pilot studies suggest that the daily and neuropsychological functioning of individuals with deficits after being in the ICU can be meaningfully improved.8 This is encouraging, although few facilities at present have the infrastructure available to provide such resources to patients in a formal and ongoing fashion.
Dr Mikkelsen: Fortunately, there is increasing interest in designing and testing care innovations to more effectively meet the needs of survivors. To date, the most promising intervention is the ABCDE bundle, which aims to prioritize sedation minimization coordinated with spontaneous breathing trials, and assessment and management of pain, agitation, and delirium with early mobility and family engagement interventions.
Postdischarge, catalyzed by the Society of Critical Care Medicine’s Thrive Initiative, there is growing interest and experience at an international level in designing and implementing post-ICU clinics and peer support groups. Rigorous study is required to discern the effect of these models of care delivery. Related effective strategies to mitigate clinical deterioration, manifest in hospital readmission, is a separate and important research priority.
Dr Jutte: PICS phenotypes can often be prevented by minimizing sedation and engaging patients in early mobilization. The ABCDE bundle is also useful for the prevention of many of the complications associated with PICS, which ideally is managed with a transdisciplinary team approach consisting of a critical care medicine physician, rehabilitation psychologist, physical therapist, occupational therapist, speech and language pathologist, and respiratory therapist, among others.
With regard to specific interventions, I will only address those that pertain to mental health outcomes associated with PICS.
Anxiety is a particularly common psychological issue faced by survivors of critical illnesses. However, to date we have limited studies of effective nonpharmacologic interventions provided during ICU hospitalization. Psychologists in the ICU incorporate modified versions of outpatient cognitive behavioral therapy (CBT). While CBT is a first-line treatment in outpatient settings, it has not yet been tested in the ICU.
Depression and depressive symptoms are also common in the context of critical illnesses and ICU hospitalization. Again, we have limited studies of nonpharmacologic interventions beneficial for depressive symptoms experienced during ICU hospitalization. We do have evidence of the psychological benefits of exercise on mood. Early engagement in mobilization and structured exercise can be beneficial for prevention and intervention. In addition, meeting with a psychologist has been shown to be beneficial, at least in one study in which psychologist intervention included aspects of CBT.9
First, we need to remember that a diagnosis of PTSD is not made until an individual has been symptomatic for ≥1 month. Many individuals are discharged from the hospital before this timeframe has been met. That said, PTSD is largely unrecognized in survivors of critical illness, although it has been estimated that ≥20% of ICU survivors experience clinically significant symptoms of posttraumatic stress during the first year after ICU discharge, and the prevalence may be even higher in patients’ family members.10,11 Also, acute stress symptoms experienced during hospitalization have been associated with later PTSD onset.12