SCCM Resource Library-You're Outta Here! Hitting a Home Run With Transitions of Care and Post-Intensive Care Syndrome

Video Transcription

Good morning, my name is Andrew Fritschli-Lodolo, and I serve as the Inpatient Pharmacy Manager at Eskenazi Health in Indianapolis, Indiana.  I'm here today as the moderator to present today's session titled, You're Outta Here, Getting a Home Run with Transitions of Care in Post-Intensive Care Syndrome.  Today's presentation will include the topics of getting into the game, transitioning from the ICU to non-ICU hospital location, how to facilitate continuum of care to home or  rehabilitation beyond convalescence, and lastly, ready for the big leagues, strategies for the development of a post-intensive care syndrome clinic. Thank you and enjoy.  Good morning. I'd like to thank SCCM for inviting me to deliver this presentation today.  My name is Rachel Kruher, and I am a Clinical Pharmacy Specialist in Critical Care at Indiana  University Health Adult Academic Health Center, and I'm a Team Lead in the Inpatient Clinical Pharmacy.  I have no actual or potential conflicts of interest to disclose for this presentation. My objective today is to discuss approaches for successfully transitioning patients from  an ICU to a non-ICU setting. Initially I'll focus on the risks associated with transitions out of the ICU, but I hope  that you'll walk away from this presentation with some additional mindfulness on this high-risk  transition and the potential harm that exists in our current fast-paced healthcare environment.  By the end of the presentation, we will explore some potential programs that may mitigate risk, and hopefully I will have convinced you that this is an area ripe with potential  for future study. As patients recover, they no longer need our high-intensity support in the ICU. Hooray.  But with this transition often comes a whole new healthcare team, a new environment where  nurses are caring for more patients, communication of large quantities of complex information must occur among multiple healthcare providers.  This puts our patients at risk for medical errors, additional potentially unnecessary diagnostic tests, patient dissatisfaction, and increased cost.  I know I'm preaching to the choir here, but it's sometimes remarkable to think about the vast amount of information that is captured at each point in a patient's hospitalization  that then must ultimately be summarized and handed off to the next team. So if you think about even pre-admission or during the admission process, there's information  care that's occurring in the emergency department, in the operating room or procedure area, potentially  even days or weeks of therapy at an outside facility, and this is all before a patient gets to our ICU door.  And then in the ICU, we have information that we're gathering from family, radiology, and  other tests, potentially emergencies and complications that have to be summarized and handed off, and then medication changes to accompany all of these things.  And then the physicians and advanced providers on the wards are given the sometimes insurmountable  task of medical optimization and discharge planning before the patient ultimately leaves the acute care setting. And we know, of course, that to err is human.  This landmark report published in the year 2000 increased our awareness of the unacceptably high rate of medical errors in the United States and their associated mortality.  Medical errors cause as many as 44,000 to 98,000 deaths per year and are the eighth leading cause of death in the United States.  This holds true at times of care transition, perhaps it even underscores the magnitude of the problem.  A large multi-center cohort study from 10 medical or surgical ICUs in Canada was published earlier this year in July of 2020, and the authors described the magnitude of adverse  events that occurred during the transition of care from the ICU to the ward. While it's usually accepted that this time is fraught with risk due to the complexity  of patients, until recently there's been a relative paucity of evidence describing the risks and associated outcomes.  The investigators in this study found that 18% of patients experienced an adverse event within seven days of transfer, 6% of these patients had an adverse event resulting in  permanent death or disability, and more than a third of these adverse events were considered preventable.  Interestingly, these events were characterized as being not predictable by the ICU or ward physician.  I think notably, those who had an adverse event had a length of stay in the hospital that was 16 days longer than those who did not have an adverse event.  They had a 5.5 times greater odds of being readmitted to the ICU and 4.6 times greater odds of dying in the hospital.  Not surprisingly, increased patient complexity and complex comorbidities are factors that are associated with higher likelihood of adverse events.  Having two or more comorbidities and specifically chronic heart or vascular disease or kidney  disease or a higher APACHE-2 score were the specific risk factors associated with adverse events.  Unfortunately, this likely makes up the majority of our ICU patients, especially now during the surge of COVID cases we're seeing globally.  Interestingly, hospital safety culture, including allocation of resources and patient to staff  ratios, including various disciplines, intensivists, nurses, pharmacists, etc., and a higher bed  occupancy in this study, defined as greater than 80% of ICU beds occupied, may contribute to an even greater extent of risk than patient-specific factors.  Additional data in this area is certainly needed. If we think about the timing of transition, it's a factor that's commonly brought up when  considering optimal time of transition of care. The ICU admission, discharge, and triage guidelines published in Critical Care Medicine  recommend that discharge parameters be based on ICU admission criteria for the next lower level of care and the institutional availability of those resources.  Of course, the timing of resource availability is never exactly what we wish it could be. The guidelines cite multiple studies that have evaluated the effect of the time of transfer  from the ICU. Discharge in the evening or night hours is an independent risk factor for increased mortality and readmission.  The reason for this is unclear, but it's potentially due to the resources available in the receiving unit.  Another potential explanation is a requirement for triage and acceptance of new patients. On a positive note, weekend discharge from the ICU has not been associated with increased  mortality. Perhaps this is because bed demand is not as high on the weekend, although I would argue  that that doesn't hold true in the current climate with our surging COVID numbers. But again, discharge from the ICU should be based on the patient's readiness for a lower  level of care. In a variety of studies, transitions of care, including those from the ED to hospital admission  or in studies looking at OR transfer to the ICU or OR transfer to the floor or hospital to post-acute setting or home with primary care follow-up, the majority of serious medical  errors in all of these settings can be traced back to miscommunication. These may be attributable to a variety of factors, including inadequate amount of time  provided for successful handoff or a culture that doesn't promote successful handoff, expectations  that differ between the senders of patients and the receivers of patients, a lack of standardized  procedures in conducting handoff, or incomplete or inaccurate medication reconciliation.  Other things including high workload, inadequate support for situational awareness, and responsibility  or role ambiguity can all contribute to these communication breakdowns, which leads us to about 80% of serious medical errors involving miscommunication during the handoff between  medical providers. So if we transition here a little bit from the sort of global look at errors that occur  at the time of transition and drill down a little bit to some specific errors, including – and at this point, we'll transition to medication errors at the time of transition.  After all, I wouldn't be a good pharmacist if I didn't spend some focus time on medications.  So I'd like to spend a few moments just on the magnitude of risk associated with medication errors at the time of transition.  The Institute of Medicine has reported that medication errors specifically are the most common type of error in healthcare, representing 19% of all adverse events and accounting for  over 7,000 deaths annually. Subsequent reviews estimate that 1.5 million preventable adverse drug events occur per  year and that hospitalized patients suffer at least 400,000 adverse drug events per year or one medication error per patient day.  Most event costs attributable to an adverse drug event was greater than $2,500 in 1997 and so is significantly greater in the current year.  Half of all medication errors occur during transitions. Medication errors occur frequently during the time of transition from the inpatient  to outpatient setting in 60 to 90% of discharge patients. The frequency of medication errors in adult intensive care units can be as high as 947  per 1,000 patient days – that's nearly all the patient days – with a median of 105 per 1,000 patient days.  So medication errors, you can see, are common at times of transition and while not studied extensively in the ICU, when transitioning from the inpatient setting to the outpatient  setting, medication errors are quite common. And medication errors are quite common in the intensive care unit where our patients are complex and are receiving complex therapies.  And so medication errors that occur from transition from the ICU to a non-ICU location within  the same institution are less well described, but as you can deduce from this, are likely very common.  I had the privilege of working with some fantastic colleagues from across the United States and  the Netherlands to determine the point prevalence of medication errors at the time of transition of care from an ICU to a non-ICU location under the same roof.  We took a one-week snapshot and captured data from all transfers out of the ICU for the same week. This was a week in August in 2016.  We found that among 985 patients transferred, 450, so about 45%, had a medication error occur during the transition of care.  And among patients with a medication error, an average of 1.8 errors occurred per patient.  The most common types of errors were continuation of a medication with an ICU-only indication, so these would be things like continuation of stress ulcer prophylaxis or treatment of  ICU delirium. Next most common was an untreated condition, so a medication that should have been ordered  but was not, so this included things like home medications that were appropriate to resume but were not. And then that was followed by pharmacotherapy without an indication.  This happened in about 12% of patients where a medication was ordered without a clear indication. And about 75% of errors reached the patient, but thankfully did not cause harm.  Errors associated with error included renal replacement therapy during the ICU stay, a number of medications ordered following transfer, so the greater number of medications  a patient was ordered upon transfer, the higher their risk for an error, and then orders for specific classes of medications.  These included anti-infective medications, hematologic agents, so anticoagulants or antiplatelet medications, and then IV fluids, electrolytes, or diuretics.  We also explored factors that were associated with decreased odds of error. These included daily patient care rounds in the ICU, as well as orders that were discontinued  and rewritten at the time of transfer outside the ICU. We weren't the first study to have found these things.  Daily patient care rounds and a robust medication reconciliation process are two essential components  to good transitions, which has been demonstrated in the literature many times in a variety of settings.  If we now step back out for a higher-level view, looking at preparing for discharge and  steps to prevent harm while we're taking care of patients in the ICU, in a large population-based  retrospective cohort study of medical patients admitted to Pennsylvania acute care hospitals  from 2004 to 2006, a multivariate logistic regression was used to determine the independent relationships between multidisciplinary rounds and 30-day mortality.  The study found that multidisciplinary rounds were associated with significant reductions in the odds of death.  The lowest odds of death were in ICUs with high-intensity physician staffing and multidisciplinary care teams.  High-intensity was defined as a mandatory intensivist consult or a primary intensivist management.  This was followed by ICUs with low-intensity staffing, which was an optional intensivist  consult or no-intensivist consult, and multidisciplinary care teams, when that was compared with hospitals  with low-intensity physician staffing but without multidisciplinary care teams. In a separate study looking at length of stay and cost in a single ICU before and after  the implementation of multidisciplinary rounding team that was caring for patients requiring  greater than 72 hours of mechanical ventilation, the investigators found a decrease in survivor  length of stay from 19 to 14 days and a decrease in hospital length of stay from 34 to 25 days, as well as decrease in total cost.  Of course, the success of a multidisciplinary team is dependent upon its makeup of members, and multidisciplinary teams, by best practice, would include an intensivist, house staff  or advanced providers, bedside nurse, respiratory therapist, case management, social work, physical medicine and rehab, a dietician, and a pharmacist.  Each member must understand their unique role during the transition and provide effective communication.  So if we take rounding to the next level, what if rounds included a checklist? So checklists have been implemented in a variety of settings, and implementation has demonstrated  reductions in CLABSI, reductions in ventilator-associated pneumonia, increased adherence with supportive  care, improved communication among house staff and bedside nurses, and decreased ICU length of stay. So I would ask, what do you think?  Could a checklist assist with transitions of care? Could a checklist help remind us to evaluate whether a urinary catheter is still needed,  whether the central line and arterial lines are still needed, whether medication reconciliation has been completed adequately, do we have durations of antimicrobial therapy, do we  have planned medication tapers for steroids or other things? Do we have anticoagulation planning during the time of transition?  If we're transitioning from parenteral anticoagulation to begin an oral anticoagulant, have we thought about cost implications for the patient's next step in their process?  Can they afford the co-pay when they go home? So then lastly, I'd like to talk a little bit about transition programs as a potential risk mitigation strategy.  Critical care transition programs are programs that provide transition services for patients discharged from an ICU to a regular ward.  They may aid in the safe transition of patients with resolving critical illness to a general hospital ward.  The health care providers that administer transition programs, including nurses, respiratory therapists, and physicians, may overlap with critical care outreach teams that provide  resuscitation for other acutely ill hospitalized patients, or they can be administered as part of a standalone ICU nurse-driven program.  The role of a transition program is generally distinct, though, from that of a rapid response or emergency response team.  In a meta-analysis of before and after studies examining medical-surgical populations describing  transition programs that were a component of a hospital's outreach team or a nurse-liaison program, the investigators found a reduced risk of ICU admission.  And notably, the risk of ICU admission was similar whether the transition program was included within an outreach team or a nurse-liaison program and did not depend on the presence  of an intensivist. On the other hand, no significant reduction in hospital mortality was observed.  So while transition programs may not have a significant impact on mortality, it does seem that they may decrease the risk of ICU admission and thus total length of stay.  These programs certainly hold promise, but may be limited by the resources and coordination needed to implement.  Additional study evaluating these programs would add to the available data. So if I could summarize, I would say that errors and adverse events are common at times  of care transition. Transfer out of the ICU is a high-risk time for error occurrence, which is influenced by both patient-specific factors as well as institutional factors.  Daily patient care rounds with multidisciplinary participation and medication reconciliation  both hold promise for decreasing risk of error upon transfer, and transition programs may decrease the risk of ICU readmission. But I want to leave you with this.  We have some work to do. Unintentional errors remain a significant problem, and they're often preventable.  Additional data is needed to identify interventions that decrease the risk of harm, decrease the risk of error, ICU readmission, and ultimately the outcomes of our patients.  So with that, I would like to take any questions that you have, and I'd like to thank you very much for having me speak about this today. Hello, everybody. I'm Carla Seven.  I'm an intensivist at Vanderbilt University Medical Center, where I lead the ICU Recovery Center, and today I'm going to be talking about facilitating a continuum of care after  hospital discharge. I do have some modest funding from the Society of Critical Care Medicine and from the Department  of Defense related to some of the research that I'm going to talk about today, and the overview of today's talk will include transitions of care, what is ICU follow-up, setting up  a clinic and identifying patients, some of the most used models and tools, some useful adjuncts to a post-ICU clinic, and things you can do to promote recovery right now,  whether or not you have a post-ICU clinic. And I want to start with this figure from Cameron and Gignac.  This is adapted from a framework called Timing It Right, and I like this because it shows us what the trajectory of recovery really is for our patients who've been in ICU care.  We are rightly focused on phase one, where the yellow gold star is, ICU care. That's where the action is and where we all like to be, and I think for many of us who  do post-ICU clinics, before I started a post-ICU clinic here at Vanderbilt, you know, if somebody left phase one, I felt pretty good about the job that I had done.  And that leads to a little bit of a blind spot for those of us in critical care, because our patients have quite a long road after they leave the ICU, and there are many transitions  which are fraught with difficulty, starting with transition to the ward, which we consider  in some ways a victory, but for patients and families often feels like a moment of abandonment and fear.  The preparation for discharge to home, which we do think about a little bit, but perhaps in somewhat vague terms, and then the early home adjustment period and late community  adjustment is something that we just have not really thought about as intensivists until recent times.  And this transition, these multiple transitions, especially the discharge from the hospital to long-term acute care or SNF or even home, which seems like it should be a happy event,  really leaves a lot of patients feeling, as Nancy Andrews drew here, Nancy Andrews is an artist and an ICU survivor who did a really fantastic series of art reflecting  on her ICU experiences. There's just this sort of black hole of a drop-off in care and attention when patients  leave the ICU, and most patients who are recovering from critical illness have no specific aftercare. So there's a period that is high risk for problems.  These transitions of care are known to be risky. I'm not sure they're known to be stressful, but they certainly are stressful for patients and families, and the challenges are many.  As you can imagine, there are communication gaps. Any of us who have read a discharge summary from our own ICU patient can see it's a little  bit like a game of telephone, and every time that the patient has a transition in their team or their location or their level of care, there's an opportunity for things to be lost.  Patients have outlined, and this is in a paper that's under review right now with Kimberly  Haynes as the first author, lapses in medical judgment and empathy are things that patients perceive.  Most patients who are in an ICU for any amount of time are really bonded to the ICU team, the nurses there and the physicians and the multidisciplinary team care that they get  there, and so transitioning even to a ward team can feel like a big change, and the step down in the amount of support that they're getting there is felt keenly.  Care fragmentation is a problem. This is especially a problem in the U.S. where our systems are not all coordinated, so I  might have a good eye on my patient when they leave the ICU to go to the ward, but if they go to a long-term acute care hospital or skilled nursing or even in many cases inpatient  rehab, they're out of my sight and out of my reach, and I'm depending on somebody at that hospital to pick up the phone to tell me how they're doing.  Adverse events are a known sequelae of transitions, and we think of somebody bouncing back to the ICU or being readmitted to the hospital as something of a black eye on our system,  but it's also a terrible thing for the patient, and loss of rehab gains is something that can be experienced even if they don't bounce back, but they're just not getting the level  of support that they need after a transition, and the support that they need changes across  the trajectory of recovery, so at each step, they may need something different, which makes it challenging to build a system that meets those needs.  So what happens to patients who are critically ill for a long period of time? This is a paper from 2010 that looks at the one-year trajectories of care and resource  utilizations for patients who were on a ventilator, trached or intubated for three weeks or more, which pre-COVID, we did consider to be quite prolonged mechanical ventilation.  I think in the era of COVID, it doesn't seem quite that unusual, and we see many patients who are mechanically ventilated for at least that long, and in this study of 126 patients  who had an initial hospitalization, sadly only 11 were living independently at the end of one year, and everyone else was just cycling back and forth through long-term acute care,  skilled nursing, acute care hospital, inpatient rehab, and you can see there are just many, many transitions that these patients have to go through, and keep in mind that most  of these patients are not familiar with the medical system and are sort of left to navigate it on their own in an impaired state.  This is some data from our own ICU recovery clinic here at Vanderbilt, and we looked at all the patients who were referred to our clinic and their ultimate discharge destination  from the hospital, and you can see that if you went anywhere sort of more severe or more intensive than home, home with home health, or inpatient rehab, you were much less likely  to come to clinic, and this was before we had a telemedicine option for our clinic, and this is one of the reasons why we developed a telemedicine option for our clinic, but  these patients were just very hard to reach, and part of this may be, of course, a marker of illness, severity of illness, and perhaps these patients who went to SNF, LTCH, hospice,  left AMA or admitted to a psych hospital did not survive much longer, but it may also be that they fell out of contact.  So I hope we can agree that these patients should have some sort of structured follow-up. Certainly, we do a lot of invasive things to people, and this patient looks perhaps  more invaded than others just because he's got everything in one place packed up for military transport, but unfortunately, at least in the U.S., the existing standard for  the wide range of problems that we see after a critical illness, although perhaps best suited to a variety of specialists, really falls on the general practitioner, so most  patients, if they get any ICU aftercare or post-hospital follow-up, they will see their general practitioner, and unfortunately, we also don't give the general practitioner  very much information, which is just one more transition of care that we need to overcome. So I would argue that post-ICU patients need more.  This is a picture that a patient, not my patient, but somebody who actually happens to be an  ICU nurse who contracted COVID early in the pandemic, he posted these pictures of himself on the web just to show sort of the dramatic visual of what happens to patients after a  prolonged critical illness, and you can see this quote from him, I couldn't hold my cell phone, it was so heavy.  I was very sad to see some of the comments, of course, when you get your news from BuzzFeed, I guess this is a danger, but a lot of the comments commented that he had just stopped  taking whatever muscle-building supplements he was using pre-COVID, but in fact, this after picture is very typical for the patients that we see after a prolonged critical illness  with malnutrition, muscle wasting, you can see he has temporal wasting, very weak shoulder girdles, his streak has been decannulated, he still has a PEG tube, and significant weight  loss. So what can we do to better serve these patients? As I mentioned, most patients will get their ICU aftercare with a primary care physician  without any specific infrastructure, but ICU recovery clinics, also known as PICS clinics or ICU follow-up clinics are becoming more common, many of these clinics have come into  existence in the past year as post-COVID clinics in an attempt to deal with the very severe sequela that we're seeing after COVID and in very high numbers.  Many of these clinics have also adopted telemedicine or have been forced to have only telemedicine  clinics in an attempt to physically distance and because of infrastructure limitations during the pandemic and peer support has been an adjunct for an ICU recovery clinic model  both before and after the pandemic. Here at Vanderbilt, our peer support group is also completely telemedicine at this point or telehealth.  So if you want to develop a post-ICU program, how can you structure your teams and programs? First of all, there's a lot that can be done in the hospital and should be done in the  hospital. I like to think of the ICU recovery period as starting during the critical illness and  so as soon as the patient is expected to survive, we should be preparing them and their families for the long recovery ahead of them.  This may include things that can be done in the ICU or on the ward including ICU diaries,  nurse visits with anticipatory guidance, and social work in preparation for the socioeconomic impacts that they will experience after they are discharged to home.  Once they're at home, home health, telemedicine, and case management interventions can all be delivered in the home environment.  And then the concept of a multidisciplinary post-ICU clinic can involve a variety of disciplines.  I've highlighted here in yellow the ones that we have here at Vanderbilt, but the others  are things that are certainly on my wish list and are used in other centers including physical  therapy, occupational therapy, speech therapy, nutrition, palliative care, social work, and spiritual care.  So how can we identify which patients will best benefit from an ICU aftercare program? There certainly are some characteristics as outlined here in this SCCM consensus statement  from 2020 that may suggest or predict who will develop more severe sequelae after critical illness.  So for example, the cognitive effects of PICS may be seen in patients, of course, who have preexisting cognitive dysfunction.  But we also know that delirium and heavy sedation, especially with benzodiazepines, predict post-ICU deficits.  And early symptoms of anxiety, depression, or post-traumatic stress disorder after the critical illness may predict more severe sequelae.  This box here from Wauer et al., which was published in 2020, was an attempt to use models at the time or measurement tools at the time of hospital discharge to predict who will  have post-traumatic stress in the post-hospital period. Physical function, it's no surprise that those who experience sepsis, shock, hypoxia,  or life support will have more profound physical function decrements. And then mental health, I think one of the things to highlight here is that memories  of frightening experiences in the ICU or in the peri-ICU period may predict post-traumatic symptoms thereafter.  And it's important to remember, as I mentioned before, that the support needs change over time.  So starting in the ICU, we can prevent post-intensive care syndrome to some degree by careful application of the A to F bundle.  When patients leave the ICU to transition to the ward, that's a good time to give them some anticipatory guidance.  More education is needed as they prepare to discharge for home and aggressive attention to discharge planning can really ward off a lot of the problems that we see in a post-ICU  clinic.  In that early home adjustment period, we're seeing a great benefit from telehealth because we can reach patients in the home, patients who perhaps pre-telemedicine were too weak  or impaired or their families were not available to bring them back to a physical clinic.  And then in the late community adjustment period, perhaps as an adjunct to a post-ICU  clinic, peer support can be very helpful. And this can be done in a variety of models that have been described by the Thrive Network.  And these may include in-person or telehealth options, especially now during the pandemic.  Some of the components of an ICU recovery program that you may want to consider are highlighted here.  This is from the Cairns study, which shows some of the more prominent features of multidisciplinary post-ICU clinics that are in existence right now.  These include care coordination, providing educational materials, goal setting,  normalization and expectation management, and socioeconomic support. These are the things that patients and families actually highlighted as being the most important  components of an ICU recovery program.  And once you get a patient to clinic, there are a number of screening tools that you can use to try to identify impairments and tailor therapies and further referrals.  There was strong agreement in the SCCM consensus statement of 2020 to use the Montreal Cognitive  Assessment Tool to measure cognition and the hospital anxiety and depression scale to measure anxiety and depression.  There was less consensus on how to screen for post-traumatic stress disorder or physical function, but the impact of event scale and the six-minute walk tests are both widely  used, as is the EQ5D.  Some useful adjuncts for an ICU aftercare program, as I briefly mentioned, an ICU diary and peer support are both really key support mechanisms for patients.  Many programs will have the option to visit the ICU available for patients, and this may be in conjunction with their visit to a post-ICU clinic or separate from that.  And I just want to say one more thing for telemedicine, because this is something that we've all had to learn a lot about in the last year.  We at Vanderbilt are doing a study called Teleport, trying to deliver a telemedicine  intervention version of our post-ICU clinic compared to usual care. And we've already learned a lot from this, including the fact that we can reach these  patients at this critical time, usually much earlier than we're able to get them back to a physical clinic, especially now.  The startup costs are really minimal, excepting, of course, your staff and your staff's time.  But you can pull your multidisciplinary team members in from afar. So if people are working from home, they can all be linked in via Zoom or another HIPAA  compliant telemedicine conferencing tool.  You can see the family members and often the home environment, and it's an opportunity to screen and triage these early post-ICU, post-hospital problems.  The disadvantages are, of course, that there's limited objective data, although with our implementation of COVID-to-home programs, a lot of our patients actually now have pulse  oximeters, so we at least can get some vital signs. We can measure their oxygen and their heart rate.  And there's a fair amount of physical exam you can actually do visually, which has been helpful in many circumstances. There still are some regulatory hurdles despite COVID.  So, for example, there are some limitations about where you can do telemedicine. In many cases, most cases in the U.S., you need to have an active license to practice  medicine in the state where the patient is. So here in Tennessee, if I have patients in Kentucky or Alabama or Georgia or Mississippi,  all places where I have patients, I need to have an active license there in order to  deliver telemedicine to the patient.  This has led to some awkward situations where the patient bundles their telemedicine visit  for their hair appointment, which is just over state lines, but in any case, it's something we need to pay attention to.  It's unclear whether payers will continue to reimburse for telemedicine the way they have been during the pandemic, but I think there's been so much uptake on the part of  both clinicians and patients and families that it is likely to continue to be reimbursed.  And despite these improvements, there's still a number of barriers to preempt.  Lack of funding remains a problem.  Finding a recurring space where you can have a physical clinic has been identified as a problem. These are all things that clinicians who do post-ICU clinics have identified.  Identifying the appropriate patients and recruiting them and scheduling them and the logistics  of getting them back to clinic are still challenging, telemedicine notwithstanding, and getting patients and families to actually attend these clinics has been a problem since  really their inception. Often, when people contact me and my colleagues about how to start a post-ICU clinic, we're  often asked, what is the return on investment, a term I put in quotation marks here because  I dislike it, but until recently, we really did not have a good idea of what the financial impacts of a post-ICU clinic might be.  There's certainly a lot of arguments that one could theorize that compared to ECMO, or proton beam therapy, for example, the costs are quite low, but Karen Korczak and  her colleagues here at Geisinger put together this very important piece of data from their post-ICU clinic, which is a pretty comprehensive, multidisciplinary team clinic.  It leans heavily on case management. The case manager has a lot of touch points with the patients even before their visit.  They also have the benefit of working in the Geisinger system, which is a self-insured, so they were able to estimate cost savings, even accounting for the time for their staff  and their intensivists and the resources that were put into the clinic. Even given that, based on the decreased mortality they saw in patients who attended the clinic,  they were able to see or estimate an annual cost of the clinic.  They were able to see or estimate an annual cost savings in the $250,000 to $425,000 a  year, which is significant in that it is certainly not a loss, and there are a number of benefits to post-ICU aftercare programs that may be difficult to measure financially.  At this point, if you are wishing that you had a post-ICU clinic and you don't have one and you need some time to get it started, that's okay.  There are certainly things that you can do right now to improve transitions of care for ICU patients, even without a clinic.  This is a graphic that a number of people who are involved in the post-ICU realm put together at the beginning of the pandemic to help the hospitalists who were bearing  the brunt of COVID admissions and discharges, to help them troubleshoot some of the things that we see most commonly in post-ICU clinics as being missed or suboptimally handled at  hospital discharge.  I think this makes a nice little pocket card. Chelsea Harris put the graphics together.  Basically, there are these dirty dozen points to cover, including did you restart their home meds? Med rec, as we just heard, is a huge opportunity for errors in transition of care.  Did they get meds in the ICU that they don't need anymore? Can we stop those? Do they have an anticoagulation plan?  I would also venture to say that if they have an anticoagulation plan, that it involves weeks or months that they have enough medication to make it through that course because it's  very difficult to establish care with a primary care provider in the middle of a pandemic in under then a month or two.  Who can they contact to field questions prior to the first follow-up? What is their exercise plan for reconditioning?  Prioritize the follow-up for them. Many of these patients will not be able to make it to all their follow-up appointments,  even if they are scheduled because of financial constraints, distance, socioeconomic pressures.  Did we remove everything that we put in that doesn't belong there? For example, IVC filters, strakes, pegs, lines.  Give the patient a written recap of their tubes and lines so they know what things are and also perhaps scars where things might be that they didn't know about, like ECMO cannulas.  Teach them about common readmission issues so they don't have to come to the ER just because they're scared or they can't get their questions answered.  Make sure they've got a physical therapy and occupational therapy eval before they leave.  Assess their ability to pay for what they need.  Tell them what post-ICU syndrome is.  In one of our readmission studies here at Vanderbilt, we were able to see a signal just  from anticipatory guidance by telling people, these are the sorts of things that you might run into post-ICU.  These sorts of things are a cause for alarm. These sorts of things are normal and self-limiting.  Those kinds of education pieces can go a long way to decreasing readmissions.  Lastly, I just want to point out that although we created these post-ICU programs to help  patients and families, we're actually getting a lot of benefit from them ourselves as clinicians and as researchers.  This has been nowhere more obvious than in this pandemic as we try to learn about this new disease, COVID-19.  In addition to understanding the patient experience, improving morale for the nurses and staff who took care of these very sick patients in the ICU, and finding targets for quality  improvement, we are also, at least in my experience, learning a lot about COVID-19 itself and the natural history of this disease as patients recover.  That's been extremely valuable. With that, I'll end and thank you for your attention.  Thank you.

Video Summary

The video transcript discusses the importance of transitions of care in post-intensive care syndrome. It emphasizes the risks associated with transitions out of the ICU and the potential harm that exists in the healthcare environment. The speaker highlights the complexity and information overload that occurs during transitions, putting patients at risk for errors, unnecessary tests, dissatisfaction, and increased costs. The transcript also discusses the high rates of medical errors during transitions, with one study finding that 18% of patients experience adverse events within seven days of transfer. Factors such as patient complexity and comorbidities, as well as hospital safety culture and bed occupancy, contribute to the risk of adverse events. The transcript suggests that interventions, such as daily patient care rounds, medication reconciliation, multidisciplinary teams, and checklists, can help mitigate the risks and improve transitions of care. The speaker also mentions the importance of post-ICU clinics and programs in facilitating a continuum of care for patients after hospital discharge. These programs can provide support, screening, and tailored therapies for patients recovering from critical illness. Additionally, the transcript mentions the benefits of telemedicine and peer support in post-ICU care. Overall, the transcript emphasizes the need for improved transitions of care and interventions to prevent errors and promote recovery for patients with post-intensive care syndrome.

Asset Subtitle

Patient and Family Support, Professional Development and Education, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Discuss approaches for successfully transitioning patients from an ICU to a non-ICU setting
Develop strategies for promoting safe transitions of care for patients leaving the ICU for rehabilitation facilities
Describe how barriers to transitions of care can be mitigated by a post-intensive care syndrome clinic, while highlighting the implementation process, financial implications, and key personnel needed for a successful clinic

Getting Into the Game: Transitioning From the ICU to a Non-ICU Hospital Location
Rachel M. Kruer

Ready for the Big Leagues? Strategies for Development of a Post-Intensive Care Syndrome Clinic
Carla M. Sevin

Meta Tag

Content Type Presentation

Knowledge Area Patient and Family Support

Knowledge Area Professional Development and Education

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Rehabilitation Medicine

Tag Administration

Tag Healthcare Delivery

Year 2021

Keywords

transitions of care

post-intensive care syndrome

risks

medical errors

adverse events

interventions

continuum of care

recovery

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