and I am an acute care nurse practitioner working in critical care at Mayo Clinic in Rochester, Minnesota. And I just want to thank you for joining me for this talk on PICS clinics and their necessity in the care of ICU survivors. As a bit more background, along with my bedside clinical roles, I have also been active over the past several years in work focused on post-ICU recovery. I've been the past co-chair of what was previously SCCM's Thrive Peer Support Collaborative. And most recently, I am an active founding and executive team member of the newly developed Critical and Acute Illness Recovery Organization, as well as the co-chair of the Peer Support Collaborative within that organization. I am also a founder and lead of the Mayo Clinic IC Recovery Program, which started back in 2016 with development of a peer support group. And our program has grown now to include a full clinic that we actually started in late 2019. We have now seen over 500 patients in our clinic and are continuing to expand. So it's just been a really very busy and exciting last few years for our team. This talk is going to serve several purposes, all focused on getting you more familiar with IC recovery programs. We will quickly review some history of existing programs, highlight the purpose of these clinics, describe typical composition of the clinics, and then wrap up with a discussion about the roles these programs play in patient care. Historically, post-ICU recovery clinics have been developing around the world over the course of the past two decades. Teams in the UK have been well ahead in this work than most other areas across the globe. In 2006, a survey of 289 intensive care units found that 80 of those, or 30%, reported having a follow-up clinic in place in the UK. More recently in the US, post-ICU recovery and the development of formal follow-up clinics has garnered more attention. This is in large part due to the increased focused on and naming of post-intensive care syndrome. Some of the earliest adapters to the development of post-ICU follow-up clinics in the US have included sites such as those at Indiana led by Dr. Khan and team, which opened in 2011, and Dr. Carlos Evans' team at Vanderbilt, which opened a year later in 2012. In 2015, SCCM developed the Thrive Collaborative focused on PICS, most notably on the development of support groups for post-ICU patients. In 2017, the Thrive Clinic Collaborative was developed. And by 2019, there were 10 sites total across the US that were engaged with that collaborative. And in 2020, a new organization, Critical and Acute Illness Recovery Organization, or CIRO, which I mentioned a bit earlier, was founded. And as of right now, there are 34 clinics worldwide engaged in this post-ICU clinic collaborative. So as you can see, it's really starting to catch on globally. I want to briefly discuss in the broad sense how many of these clinics function logistically, since that is a very common question that we get asked. There's truly a wide spectrum. Some clinics function with a large focus on research, while others operate in a purely clinical sense. Some clinics are very structured with set intervals for patient follow-up, let's say at like three, six, and 12 months, while others will conduct an initial assessment with follow-up on an as-needed basis. This really ties back to the first bullet here in that the more research-focused clinics tend to have that structured follow-up built into protocols so they can closely follow the patient recovery outcomes. Many clinics are brick and mortar and see patients face-to-face, while others, like ours at Mayo Clinic, are run purely virtually. So others operate more on a hybrid model. And most of these clinics run part-time, meaning these are not typically your Monday through Friday, eight to five clinics. Often, they will be offered really just a handful of times per month. For example, at Mayo, we run our clinic every other Thursday and Friday for an average of four clinic days per month, with each clinic day having seven one-hour patient appointments available. Despite the varied characteristics of post-ICU clinics, broadly speaking, they share a similar purpose, to restore the whole person to the best level of functioning possible so they can live their life to their fullest potential. So the focus is really on moving the patient out of the ICU bed through this continuum and really get them back to home, back to their hobbies and activities they enjoy, and back to work if that's applicable for them. So what actually takes place at these clinics to help patients achieve their recovery goals? Again, broadly speaking, many clinics share similar functions that help patients recover. As a reminder from earlier lectures that you may have listened to, that are most affected with PICS include the physical, cognitive, and mental health domains. Therefore, these areas tend to be the primary focus for assessment for most post-ICU clinics. To evaluate the current physical health of patients, most clinics will perform a variety of assessments and exams. Depending on the delivery of the clinic, face-to-face versus virtual, will determine how in-depth some of these evaluations are. For example, centers who hold a face-to-face clinic may have each patient perform baseline PFTs, labs, or even routine imaging, while virtual clinics such as ours at Mayo rely really on the patient interview, chart review, and review of systems and symptoms along with online questionnaires that can be very helpful. Functional reconciliation is a key aspect of post-ICU recovery clinics. Functional debility is one of the most common symptoms experienced by patients recovering from critical illness. A focused and thorough assessment of this is vital in optimizing recovery. Again, there is some variation in what assessments are completed depending on the delivery method of the clinic, but overall, the focus here is on a reconciliation of rehab activities that often start in the hospital but can easily get lost to follow up once the patient is discharged. Now more than ever, we are understanding the importance of this as we see both acute and outpatient rehab facilities being overrun and not being able to accept patients in a timely way. More patients are returning directly home when they previously may have spent time in a facility. Examples of some of the common assessments completed with functional reconciliation include assessing ADLs and IADLs, six minute walk tests, grip strength, and swallow evaluations are fairly common. Other very important aspects to explore with these patients is return to work and driving. Expectation settings for these activities is very important and in making sure that the patients have a good understanding that getting back to these activities too fast can have very negative consequences. So for example, we will often assess return to work plans with our patients and some have it laid out and they know exactly when they're going back and how they're going back. Others are really kind of left all on their own to try to figure this out. So we walk them through our guidance and our recommendations for ways to be most successful when returning to work and patients ultimately find that to be a very, very helpful part of their recovery. Cognitive and mental health evaluation is also a very common function of post-ICU clinics. Many critically ill patients experience delirium while in the ICU and the effects of this can be long lasting. Even patients who didn't have documented delirium can experience ongoing issues following hospital discharge. And unlike physical debility and functional difficulties, cognitive and mental health concerns can sometimes be those quieter concerns, right? So people can be really good at covering these things up. So a person might be struggling with brain fog, memory issues, anxiety or depression, but are able to mask many of those symptoms. This leads people to suffer in silence and not have the ability to access the help they need with that aspect of their recovery. As providers, we are also much less likely to talk about these issues either in an anticipatory way or even with standard follow-up. So the post-ICU clinic assessment of this does focus on screening for these issues. So if they are present, they can really be validated with the patient and addressed in an effective way. Tools such as the MOCA or the MOCA blind for virtual assessment can be used for a brief baseline cognitive assessment and tools like the GAD and the PHQ are often used to screen for anxiety, depression. And it's not uncommon to screen for PTSD as well. Quality of life is also often assessed during post-ICU follow-up. Other aspects of clinic that help focus on cognitive and mental health include allowing space and time for ICU debriefing, as well as sleep assessment in our patients. And finally, most post-ICU clinics will incorporate a version of medication reconciliation or medication therapy management. This will typically include a standard review of medications noting any changes to the patient's current medication list as well as an opportunity to answer any questions that the patient and family may have regarding their current medication regimen. Questions about side effects, length of treatment, dosing changes, timing of administration and others are questions that our ICU recovery team often hears during follow-up visits. This aspect of the follow-up clinic also allows time for specialized counseling on topics such as smoking cessation, as well as immunizations, which is more important now more than it has ever been. One of the central tenants that most post-ICU clinics have in common is the multidisciplinary composition of the team running the clinic. Some clinics will have many different disciplines available to the patient at each appointment. So for example, patients may meet with a provider, a therapist, dietician, social worker and receptory therapist all in one visit. In our clinic at Mayo, which again we hold completely virtually either through a teleconference or through a video visit, we have a provider, a pharmacist and an occupational therapist present for the entirety of each appointment. We do have a social worker who provides follow-up via consultation if needed, and many other specialties that are consulted through our team if indicated during our initial appointment. The common multidisciplinary approach to the post-ICU clinic is one of the many aspects that makes these clinics unique. Just as we bring the whole team to our patient's bedside while they're in the ICU, the same type of model is practiced with these follow-up clinics. We'll spend some time next really discussing in a bit more detail the role that post-ICU clinics can play in our patient's care. A commonly asked question is why the need? How do these clinics benefit our patient systems and staff, you know, especially over typical follow-up with let's say primary care providers? And this is really a very legitimate question to ask. So let's take a look a little bit more closely at the impact that these clinics can have. A study that was published in 2019 by SCCM's Thrive Collaboratives, and which was led by Dr. Joanne McPeak, highlighted the reported benefits experienced by patients who engaged in ICU recovery programs. And this study really pulled out five main themes that are worth discussing a bit more in detail here. The first is continuity. Fragmented care was a theme that was discussed broadly in this study. Many patients felt as though when discharged from the hospital, they were left with a sense of, now what? Who do I go to? Who's in my corner? Having the ability to connect with someone from the ICU during their recovery felt very important to them and was really reassuring. These teams were able to catch things like medication changes, activity restrictions, et cetera. And that really helped the patient. It was really that continuity of that ICU team being able to interpret what was supposed to be happening for these patients after their discharge home following a critical illness and had a big impact on their recovery. Other patients who didn't have the opportunity to engage with post-ICU teams following dismissal really theorized that had they had that opportunity, they really felt like their recovery may have been more rapid. Which flows into the second theme here of improving symptoms. Critical illness really comes with its own unique baggage. I tell our patients that all the time. Symptoms and issues that may seem obscure and go undetected, if one doesn't know what to look for, you can really miss some of these issues. Things like significant hair loss, for example, or new neuropathies, memory and cognitive difficulties, and a whole host of emotional difficulties that people can experience following critical illness. ICU recovery programs are unique in that these issues are screened for and managed if present. Whereas in other settings, the provider's clinicians may not even know that these can be consequences of critical illness. Patients benefit from the expertise that clinicians in ICU recovery programs have, not only with critical care, but also with the more unique recovery needs that these patients have. Screening for these issues and managing them if they are present is really key to a meaningful recovery for our patients. And this piggybacks nicely onto the next theme found in a study, which was expectation management. And I can't tell you the number of times I have had a patient say to us during our clinic appointments, I had no idea my recovery would be so slow. I thought I'd be so much better by now. And this has been especially true, we've noticed during the pandemic. ICU recovery programs really have the advantage of helping set appropriate expectations for patients regarding their recovery. By doing so, patients can set achievable goals that will really set them up for a successful recovery versus a recovery full of frustration and perceived failure on the parts of the patient. Validating one's experience with critical illness is a very important role of the ICU recovery program as well. This can be done in many ways, including ICU survivorship visits, which admittedly have gotten more complicated since the pandemic. This is where patients will go back to the ICUs and visit the ICU where they stayed and visit with staff. These types of visits can be very beneficial in both directions. They really let the ICU staff see how well these patients are doing. And that helps to reemphasize the importance of the work that the ICU staff does. It also allows the patients to see how far they have come while giving them the opportunity to talk with the ICU team members and thank them for caring for them during their ICU stay. Follow-up appointments with an ICU recovery team also allows time to affirm with the patient how far they've come and the credible amount of work has taken them to get where they are. This can also occur through activities such as ICU debriefing or ICU diary programs. This type of affirmation can go very far, especially for patients that are facing these prolonged recovery trajectories. Another role for validation that ICU recovery programs can provide is by acknowledging the real struggles that patients and families face once they are out of the ICU. While the rest of the world just seems to keep spinning as usual for patients and families recovering from critical illness, things can look a lot different. Having a team that can really hold the space for that and validate the legitimacy of those feelings can be exceptionally helpful to our patients. And finally, support. ICU recovery programs create unique and invaluable networks of providers and patients who have experienced something very few people ever have to deal with in their lifetime. By being able to speak with others who are intimately aware of the impact that critical illness has on a person, real healing can begin. Some programs offer formal support groups for survivors and families, while others do this more informally with follow-up. There are other roles that ICU recovery programs play in patient care, even if maybe less directly. In another study published in 2019, again by SCCM's Thrive Collaboratives, this time led by Dr. Kimberly Haynes, five key mechanisms driving improvements on the ground right in the ICU through the existence of ICU recovery programs were described. So these focused on the system as well as impacts on the clinical staff, which ultimately will lead to impacts directly for the patient. As you can see in the graphic from this study, from an organizational standpoint, ICU recovery programs can influence the ICU by identifying new ideas for QI projects, like for example, improvement in transitions of care. Other influential aspects include empowerment of survivors to take more official roles within the hospital for educational and support purposes, as well as providing the opportunity for other colleagues to experience the post-ICU clinic firsthand. This type of experience where colleagues will come in and observe the post-ICU clinic has been especially helpful for those in administrative roles. So they can see the process and the value of these clinic, especially when decisions regarding funding or expansion are on the table for these clinics. ICU recovery programs also have direct impacts on the clinical staff, which loop back and impact patient care. Seeing patients after their hospital and ICU stay when they've been able to get back home and back into their lives, gives a much clearer picture of how the interventions performed at the bedside impact our patients. Hearing firsthand from patients what they can remember, what they hear, feel and sense while in the ICU can be completely transformative to the way one delivers care at the bedside. I can say with 100% certainty that I am a different provider at the bedside today, thanks to my work in our recovery program. And finally, improving morale within the ICU, which is needed now more than ever, directly impacts our patients and is yet another way the ICU recovery programs can be influential. One of the greatest joys I have in my role in the recovery program here at Mayo Clinic is when I get to share back a message from a patient or a family member to the ICU team that took care of them. It's healing for everyone involved. It helps reinforce that significant impact we all have on our patients in the ICU. So to summarize all of this for you and to give you some quick take home messages, ICU programs are expanding across the globe and they vary widely in their characteristics while really sharing a fairly common purpose of restoring the wellbeing to our patients as best as possible. Common to many of these programs, a central aspect is really the multidisciplinary team model that is so important to its overarching purpose. And finally, ICU recovery programs play many important roles in the care of our patients, either directly through clinic care or more indirectly through organizational processes. Thank you so much for joining me for this really important conversation about how we can impact the lives of our patients with post-ICU recovery programs. For any follow-up questions or comments, please don't hesitate to reach out to me through the contact information that I have listed here and enjoy the rest of your Congress.

ICU recovery programs

post-ICU clinics

care of ICU survivors

multidisciplinary team

physical and mental health issues

continuity of care