I can't believe all of you hung in here. It's almost four o'clock. Thank you so much. So my name's Tammy Eaton. I am a nurse scientist. I'm a health services researcher. And I'm finishing up my second year of being a research fellow with the National Clinician Scholars Program at the University of Michigan. And I've been asked to talk a little bit about how we're currently caring for ICU survivors. As a side, I've spent about, I'm gonna show my age, 25, almost 30 years in critical care. And about seven years in the criticalness survivorship world. Before I came to Michigan, I was with the University of Pittsburgh, one of the founders of the post-ICU program, AUPMC Mercy, which we opened in 2018. So I have a lot of thoughts about this topic. My disclosure slide. All right. Some of this will be repetitive, but I'm not gonna talk repetitively. And being a critical care clinician, at the University of Pittsburgh, I was fortunate to work as the program director for the process study under Dr. Derek Angus. And it was so amazing that we were looking at one-year outcomes. We're high-fiving, we're trailblazing. And the thing is, as Dipali said before, about 80% of patients are initially surviving the ICU. And that key word is initially. What's happening to these patients and their families, it should be concerning to all of us. We need to start investing in ICU survivor care and reframing how we think about their journey. Like as intensivists, in our love languages, save, rescue, liberate, recover. But now, and we're still using these words after the ICU. Instead, I think we should be considering words like adapt, adjust, transform. Because that's what our ICU survivors are really doing. And we were able to cover PICS before. But again, just to repeat that alarming statistics that 50 to 70% of survivors are experiencing at least one component of PICS. But PICS is just one of our worries. About 30%, and this was mentioned before, experience unplanned hospital readmissions. And this is in the first six months. With about a quarter of those patients being readmitted to the ICU. These survivors are at five times greater risk of new and worsening chronic illness. And about 20% of them are dying in the first year. And then obviously stemming from all of these persistent dysfunctions that they're having from PICS, and that significant symptom burden, the pain, the fatigue, the sleep disturbance, anxiety, depression. The social consequences of surviving a critical illness are really what we're starting to focus on. Because they're immense. They're affecting quality of life. They're affecting our patient and their family's ability to regain independence and remain employed. And just how it affects that informal caregiver. The result of providing that ongoing care after the ICU, after the hospital. We're seeing reduced work hours in family caregivers. We're seeing reduced income causing financial toxicity. So the big three approaches to ICU aftercare that I'm gonna talk about, in response to all of these impairments, are these interprofessional ICU aftercare programs. They're being employed internationally. They're a resource to screen, to diagnose, to refer and manage our survivors of critical illness and their families. And although our primary care teams provide a lot of follow-up care, just the volume, it's impossible. So these specialized ICU aftercare programs, they're actually offering that extra layer of support for these unique health issues. So ICU recovery programs, and please, I don't want your heads to explode seeing all these different disciplines here around the ICU survivor and family caregiver. I know what you're thinking. How are you gonna fund this? How are you gonna operationalize something like this? But ICU survivor care is a team sport, right? And this is where your local resources come into play. Every program that I know about, it looks different. You use what you have. You begin talking, educating your institution about critical and survivorship. I guarantee you, you're gonna find others, whether it's in your discipline or outside your discipline, that wanna be involved in this. And there's a lot of programs over the last couple of years that have leveraged that need for post-COVID care, or post-COVID critical illness care, to create a program to accommodate non-COVID critical illness survivors. And I mean, generally speaking, there isn't one clinician that's more or less important to the care of the patient. And I know I see Dr. Montgomery Yates here. I'm gonna use her as an example from the University of Kentucky has a very robust post-ICU clinic and program. And last year during a webinar, she had shared that one of the most monumental things that she had done for a recent patient that she saw in the post-ICU clinic was his trach decannulation. So feeling like as the intensivist, as the outpatient physician, I'm the most important person during this visit. But however, his mother and he shared that it was actually the help that they got to get their home electricity back on. So that enters my plug for social work. Again, this is a team sport. So just to give you a quick example of like what this looks like. So at the University of Pittsburgh, UPMC Mercy, when I was still there, our program consisted of the pharmacist who did med reconciliations. They provided vaccinations. They did a lot of medication education and really looking at access to medications. We had rehabilitation services, physical therapists who would assess their physical functioning and their endurance. The occupational therapist was looking at ADLs, IADLs to see if they were able to actually go back and even doing home safety evaluations. Like when they go back, can they actually get around the house or are they gonna hurt themselves when they get back? A speech therapist, they administered a mocha, did a cognitive evaluation and actually did a swallow, bedside swallow to see, because as you know, a lot of our patients are prolonged intubation. We did see some stroke patients, so we wanted to make sure that that was safe. We also had a dietician, which it was actually the ICU dietician that would come in, look at that weight loss. They actually even created a cookbook of easy to prepare recipes, because their endurance, they just don't have the endurance or even the strength to lift that pan to cook something. I worked in the clinic as an advanced care or advanced practice provider and palliative care nurse practitioner, and then our physician. And we had a bunch of learners. We had pharmacy residents, we had critical care fellows, and we were very fortunate to be able to add a social worker. So the social worker, to kind of squeeze them into this type of program, you can use them twofold, like for resource allocation, disability, food insecurity, travel, transportation, but as a licensed clinical social worker, they can also provide short-term psychotherapy and bridge those patients with mental health needs and then actually connect them with a longer term therapist if needed. So that's just my experience. And the patients we're seeing, these are patients that, the highest risk for post-intensive care syndrome, sepsis patients, respiratory failure, delirium, COVID-19, and the ICU. And we're seeing a lot of evolution in how these programs are being delivered. Some of them are in person. There's many more that are doing telehealth. We actually just had a paper out of Vanderbilt that just went into chest. It was a qualitative paper looking at patient and clinician interactions during a telehealth visit and how we're trying to meet those needs during a telehealth and looking at the feasibility of that. But there really isn't a current standardized model. One of the studies that we did last year was actually looking at how COVID-19 has changed the care delivery. So these same ICU recovery program clinicians, multidisciplinary clinicians were interviewed and these are the things that they said that were changed in either their practice or at the program level. They were integrating social care more. They were expanding their care delivery modes. And then as a clinician, they were recognizing that financial aspect, refining their communication skills and really focusing on reconstructing the illness narrative because over the last couple of years, we didn't have families in the ICU that could fill in the blanks for these patients. They have large memory gaps and how distressing it is for ICU survivors to try to make sense of what happened and not have a family member at the bedside that said, I was there that day and fill in the blanks. Another mechanism is the peer support programs. Again, there's multiple models that are out there. There are some programs that actually provide information sessions that's led by content expert. They may have an occupational therapist talking about energy conservation or a dietitian talking about diet. There are modes that are group sessions facilitated by ICU staff or a psychologist, social worker. There are some programs that are venturing out into peer-to-peer mentoring where they have a more senior ICU survivor mentoring a newer ICU survivor. There are, like Mayo has an online discussion board. And because of COVID, we've learned we can do this through Zoom. We can do this through Teams. Teams kind of stinks, but Zoom. Yeah, Teams is harder. Zoom is great. And we're able to capture at the University of Pittsburgh, they're capturing patients nationally. So it's not just patients that are seen at UPMC, but they're capturing patients all over the country now. This figure here shows the mechanisms by which peer support provides benefit. This is work that came out of the Thrive Initiative, SCCM's Thrive Initiative, looking at what patients and families thought provided the most benefit to them and how it benefited them. And I won't read off the slide, but... And then ICU diaries, one thing we haven't talked about today. This is really a unique approach to how the patient and family reflects on the critical illness. It really helps that ICU survivor make sense of the time they lost, whether it's sedation, delirium. And the important piece of this is the debriefing part of it. So not just having patients, I mean, having staff and family write in a journal and just handing it to them and saying, oh, good luck. I mean, that's a lot to give to a survivor and family, but having some type of scheduled debrief to really process what happened. This systematic review, I think, kind of sums it up, like how patients feel about the ICU diary the technical portion of it and the emotional portion of it. And they really felt that it helped filling memory gaps. It humanizes the ICU staff to them and it strengthened the bond that they had with their family. And then just that the idea of the ICU diary itself and having pictures and having, they wrote messages of love and going over it with the ICU staff was very helpful. So I would like to put a little bit of a plugin for this. So the Critical and Acute Illness Recovery Organization, or CHIRO, this is an organization that actually evolved from SCCM's Thrive Initiative in 2019. The mission is to promote, support advanced innovations in critical and acute illness recovery. We currently have over 45 clinical sites across six countries. And there are two major collaboratives that are a part of this. There is a clinical post-ICU clinic collaborative and a peer support collaborative. And this is interprofessional. This is multidisciplinary. This is pharmacists on the call with nurses, on the call with doctors, on the call with social workers, trying to work this out. And I think this type of learning collaborative mechanism, I mean, it's important, if you're interested in doing this type of work, it's important to find your people that are doing this work outside of your institution. Because you know what? If you're having a problem with something, I guarantee you somebody else already had that problem. And we hear it over and over again every year as new sites join. And this learning while doing model in developing clinical practice is working. I mean, we're not a room full of cardiologists that can pull out our Rolodex of RCTs on ICU aftercare. And I know I showed my age again, Rolodex. But we don't have that to guide our practice at this point. So this is an appropriate choice for, you know, as we're building evidence-based practice. And I mean, it has face validity, just it kind of feels like the right thing to do. So to summarize, lots of cool multidisciplinary work happening in the ICU aftercare space, post-ICU clinics, peer support programs, ICU diaries. And I think it's gonna be exciting over the next couple of years to see what we come up with. Thank you very much.

ICU survivors

investing in ICU survivor care

interprofessional ICU aftercare programs

peer support programs

ICU diaries