Thank you for that kind introduction and thank all of you for allowing me to talk to you today. So I have nothing to disclose. So the objectives today are going to be to define post-intensive care syndrome, or PICS, and post-acute COVID-19 syndrome, or PACS, to describe current layouts of PICS and PACS clinics, and lastly to discuss the role of virtual PICS and PACS clinics. So for those of you that are not familiar, when we think about PICS, unfortunately this is a syndrome that was discovered, or I should say put into words, a few years ago by Dale Needham and colleagues. And essentially what happens is patients, they leave the hospital, and unfortunately never really recover to their baseline. So they continue to be readmitted to the hospital, and they just never really get better. So there's three different areas of impairment that we think about that comprise PICS, the first being physical impairment. So this would be patients that have impaired pulmonary function tests. And so these really, once again, even after five years, there's data that these never really return to baseline. The second of these being mental health. So patients might be depressed, they might be anxious, and they might have post-traumatic stress disorder. And the last of these is cognitive impairment. So we think the primary one of these that we think about is functional impairment. So that patients can't do things such as maybe balance their checkbook that they would normally be able to do. So post-acute COVID-19 syndrome, I'm going to walk you through this very informative figure from Nature. So essentially if you start on the left-hand side, this essentially shows when someone is exposed to COVID-19. And it shows once they're diagnosed. And if you look at the far right-hand side, this shows some of the sequelae that patients might be experiencing weeks or even months after COVID-19 that really just never goes away. So what are some of these sequelae? So when we think about the different organ systems that are affected long-term from COVID-19, the first might be hematologic. As I'm sure many of you all in the audience are aware, unfortunately many of these patients develop clots. They might have a DVT or they might have a PE. From a cardiovascular standpoint, they might have cardiomyopathy. From a GI and hibatobiliary standpoint, they might have refractory diarrhea or constipation. From a neuropsychiatric standpoint, very similar to PICS. They might be anxious or depressed or have post-traumatic stress disorder. From a renal standpoint, unfortunately some of these patients not only develop acute kidney injury, but it doesn't actually get better once they recover from COVID-19. From an endocrine standpoint, tons of new diagnoses of diabetes. From a dermatologic standpoint, I'm sure many of you all have heard of COVID toes, so these interesting red-ish purple rashes that people got on their toes during COVID-19. From a pulmonary standpoint, kind of also what I talked about from PICS, so patients that have impaired pulmonary function tests that really just never return to baseline. So what are some of the characteristics of post-ICU and post-COVID-19 recovery centers in 29 different centers within the U.S.? So Ashley Brown is in the audience who led this paper, so happy to talk about this when she's here. So with regards to numbers of hospitals, as you can see, it's very similar between the number of PICS and PACS clinics. And so not surprisingly, PACS clinics really haven't been around as long as PICS clinics. And when you look at the clinic visit delivery, as you can see here with regards to PICS clinics and PACS clinics going down to the telehealth and in-person, there's more PICS clinics that have the combination, but there's not a small number of PACS clinics. And then the number of clinic days per month were very similar between groups. It's important to note here that some use telehealth, some use in-person, but a number actually have a combination of using in-person and telehealth-type visits. And at my clinic that I work at at Vanderbilt, that is what we do. So we see some patients in person, and we also see others virtually. So let's look at kind of the history of ICU recovery clinics. As you can see here, our clinic at Vanderbilt was really the first one that was developed in 2011. And so over the years, there have been more and more and more of these. And then in 2020, secondary to COVID, there was a huge increase in this number of clinics. So really dividing this out specifically over the year of 2020 and 2021, you can see that so many of these different clinics have been started secondary to COVID. So what are some enablers and barriers to implementing PICS clinics? I really just want to focus on two barriers. So patient and family lack of access to clinics. So it makes sense that if people can't actually get to the clinic, which is quite often the case in Tennessee, since a lot of our patients don't actually live in Nashville, they might live hours away in Tennessee or even be from Kentucky. The second being lack of space. I think if you talk to anyone who started a post-ICU clinic or a post-COVID clinic, they would tell you finding space can be hard. So our situation, we actually see patients two Fridays a month during the afternoon in the pulmonary clinic because no one wants to have clinic on Friday afternoons. That's the only way we got space. So what are some factors that have influenced engagement with in-person ICU recovery clinic services? So this was a paper that was published by Leanne Bain in the journal Critical Care earlier this year. So this was a consecutive case series of prospectively collected ICU recovery center data. So 251 adult patients were admitted to an ICU and then referred to an ICU recovery center after discharge. And then we looked at scheduling and completing an ICU recovery center visit and really what affected that. So as you can see here, there are 128 clinic visits that were scheduled and 91 visits that were completed. And doing a multivariate logistic regression for factors that decreased the likelihood of ICU recovery center attendance, as you can see here, home to clinic visit. People could not get to the clinic. So how do we fix this? Telehealth. There was also a decreased likelihood of scheduling and attending an ICU recovery center appointment for every mile distance between the patient and the ICU recovery center. So now we're going to move on and we're going to look at patient and caregiver experiences with a telemedicine ICU recovery center. So this was a qualitative exploratory cross-sectional study. So telemedicine ICU recovery center visits were conducted at 3 and 12 weeks post-discharge following critical illness. And patients and caregivers, when available, met with an ICU pharmacist, an ICU physician, and a neuropsychologist via Zoom. So now we'll look at some thoughts from patients about their telemedicine visit. So some really liked it. They thought it was convenient. They could do this from their house. They didn't have to drive. They didn't have to park. They didn't have to find child care. It worked well if we were trying to take care of a debilitated patient. And they really felt like the visits were more focused and thorough, that everybody got on the call, we figured everything out, and there wasn't a lot of wasted time. So these are some quotes from patients. There but just a very short time. Then I'm back three hours on the road again. I don't have serious problems going on. Then what I'd rather do over the phone. It works better for him to do telehealth visits. He was on oxygen, and it was hard for him to take his stuff with him and actually go to a doctor's appointment. I felt like I almost talked to them more than I would have if I'd had an appointment. I could just relax and let my thoughts flow. The second big thing to note is when we see patients in person, we each individually go in and see the patient, versus when we use telehealth, everybody sees the patient at one time, which has some pros and has some cons. So these are more quotes from patients. Everyone at once being able to hear me and my story instead of repeating myself multiple times. A computer, a laptop, or tablet, but a phone is not good for it. There were too many people coming at me at once. What's wrong with me? Why is my brain not picking up on how to do that any better? It was embarrassing to be in front of everybody that I was struggling with so bad. So as you can see, some people like it from a convenience standpoint, but some people were embarrassed that they had to be in front of so many people at one time. Other thoughts that we got were caregivers told us that, essentially, if they hadn't initiated this visit, that the patient would have not attended. If he had to set it up, he would have been too frustrated. Nope, not me. I'm the designated driver. It's a lot easier because it's difficult for him to get in and out of a seat to drive. At no point in time have we felt alone. The team has been very helpful, not just been a walk-in, walk-out. So now we're going to look at a multidisciplinary ICU recovery center visit and other qualitative analysis of patient-provider dialogues. We actually found two different themes. We found problem identification and also problem solving. So this, as I said, was a qualitative descriptive study in a telemedicine multidisciplinary ICU recovery center at a tertiary academic medical center. And patients and caregivers, when available, met with an ICU pharmacist, an ICU physician, and a neuropsychologist via Zoom within 12 weeks of being in the ICU. So these are some of the problems that were identified. So with regards to health status, I don't know especially which one because I take all of them at once. I just know I do sometimes, and if I get up too fast or get to moving a lot, I get just nauseous and throw up sometimes. I don't feel no shortness of breath. I can breathe. I feel good. I know she said it was my left lung, and sometimes at nighttime my wife says that when I sleep, when my mouth opens, she can hear a crackling sound, and it was the same sound they heard when I was in the hospital. When I look at some medication management problems that were identified. So what is that one for? You know what? Because I don't remember. I know it. Yeah, because it's three a day, and I think they gave me for like when I left the hospital, like for two or three weeks. So I haven't took them for maybe a week and a half now. I tend to miss like one a week, more the nighttime one, because sometimes I just fall asleep before I take my medicine, and then the next thing I know it's like 5 o'clock in the morning. So definitely problems with medication compliance. And then looking at mental health and cognition problems that we found. So recently, since he's come home, he did tell me of one that he woke up from where in the dream he felt like he was dying, and he thought he was going to die, and then he saw me, and he felt like he was going to be okay. For about five or six days afterwards, even after I was home, I had word-finding difficulty, where I like, I don't know, it's the word-finding difficulty. Like I say it in my head, but my mouth won't say my words. Also problems with health care access and navigation. I was trying to get a copy of the CT scan that was done, but I didn't know who to ask. So I asked Dr. X, and they were like, well, she didn't request it. You must ask the person who did. I'm like, well, I had it done in the hospital. I have no idea where a litany of doctors there. Who do I ask the question to? Every time we try to make an appointment with them, they call us, and then we call them back, and then they won't. I can't remember what she said. They wouldn't see him for some reason or other, and I can't remember exactly now, but we've been trying to get him some insurance, and everybody just keeps turning him down. It's very frustrating. Also problems with quality of life. So this was in response to a question, have you been driving? I drove up the driveway, but I've got about half a mile up the driveway, and I just went up there and turned around and came back, but no, I have been driving on the road. I haven't been driving on the road. It's still pretty shaky. And then it's weird because I work on Tuesdays and Thursdays, but for some reason I seem to have trouble sleeping on Monday nights and Wednesday nights, probably because they're anxious about going to work. So what were some of the problem-solving strategies that we helped identify? So with regards to facilitating care, one strategy that we came up with is, I'm going to copy a number of your different specialists on the notes, so they'll know if you still have questions. Or when we finish, we want to make sure that you know all your meds that you need refills on. It sounds like the apixaban and the atorvastatin are the two that we're out of or almost out of so far, correct? We also helped with patient education and guidance. So even if it feels hard to walk with a walker without it, just try to do as much as you can. Rest and then do some more, and that will help you build up your muscle. That's really an important medicine because if you don't get the full treatment course for the blood clot, then the blood clot can get bigger and it can extend, and that's also a place where bacteria like to hide. So in general, we want to make sure that you have thinner blood. So what are some of the pros and cons of telemedicine? I've told you some of the things that patients have said. Some of them really like it just because it's convenient, they don't have to travel, they don't have to figure out about child care, they don't have to drive. And some of them didn't like it because everyone was together and they really felt like they were being bullied at points. So your advantages are you can reach patients at a critical time. Maybe they're not able to drive or maybe they don't feel comfortable riding in a car. The startup costs are pretty low. All you really need is a Zoom account. And it was really advantageous for us because even if we all weren't at the same site, we could see the patient together. You can pull in a multidisciplinary member from afar. So even if someone is really far away, it would still work. You can see the family in the home. This has been very telling for us. We had a patient that had a history of alcoholism, and we were asking him about that, and behind him you could see a full bar. So it was just very interesting. Also, you can use it to really screen and to triage patients and see if they do need to come in because the disadvantages, as many of you all would know, is you can't do the pulmonary function test or you can't do a six-minute walk test. You can see if they need to come in and to perform those tests. Disadvantages include limited objective data. As I said, you can't really do a physical exam. There still, unfortunately, are some regulatory hurdles despite COVID-19. There were points during the pandemic we would have to have people that lived in Kentucky just come pull over the line into Tennessee so that we weren't breaking any laws. And that's really just unfortunate that you have to do things like that. And also it's unclear whether or not payers will continue to reimburse. So in conclusion, PICS and PACS clinics are increasing in number. The distance from in-person PICS clinics is definitely a barrier to attendance. Virtual PICS and PACS clinics are appreciated by most patients and caregivers, and an interprofessional team is key to providing the best virtual post-ICU care. And that concludes my presentation and I think we'll all take questions together at the end. Thank you.

post-intensive care syndrome

post-acute COVID-19 syndrome

physical impairments

mental health issues

cognitive impairment