Post ICU Clinics

[Tipsy McStagger]

Anybody involved in these, or have any thoughts? I never gave much thought to them until I started talking to people who I remembered from the unit who I felt "did well" (recovered, went to rehab, went home, back at work). The mental and physical impact that critical illness still has on them (and probably will for life) I was truly stunned to see. Nightmares, PTSD, weakness, fatigue etc.. I started to wonder what kind of a life we're saving these people for? Then I heard that some places have post-icu clinics, staffed by intensivists, psychiatry, PT/OT, pharmacy etc. Sounds to me like a wonderful way to unload their PCP who doesn't have the time to sort through everything that has happened and what meds they're now on and which specialists they need to see first...

I'm wondering what your thoughts are on the matter. I've definitely met a fair share of intensivists who turn their nose up at these clinics. I can understand that, but I don't know that they fully appreciate how broken people can be when they leave the ICU, even under the best of circumstances. Not saying we all need to run clinics, but it seems like a good way to augment a career, or even slowly shift into these clinics as the years and years of ICU start to wear on us.

Lastly, can we compile a quick list of places that have these clinics? I'd like to read more about their approaches. So far all I know is:
Michigan
Vanderbilt
Mayo
Cleveland Clinic
UPMC

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[jdh71]

The idea interests me. Too often I see people in pulmonary clinic who are just not well polished by their time post ICU by their rehabs or their PCPs. I often enough find myself ordering them all of the help they need at home or specialist f/u myself.

Probably the biggest issue here is that a good portion of Intensivists these days wouldn’t know how to deal with a clinic patient especially coming from a non IM background. Though smart and willing people can do a lot of they want to learn.

The other problem is the business side of the equation. You can’t make money seeing patients with lots of problems efficiently. Which means these will not be a regular thing anywhere.

 

[spacegun]

This is a really interesting idea to me too. I don’t know anything about it but Ive heard other nations have post ICU clinics (eg the UK) so might be worth reading about them.

 

[BigRedBeta]

Lots of standard of care defining studies came out of follow up clinics in the neonatology world, so I'm sure that for the PICU and MICU/SICU this is an untapped frontier...

 

[chessknt]

The other problem is the business side of the equation. You can’t make money seeing patients with lots of problems efficiently. Which means these will not be a regular thing anywhere.

This is the real reason why nobody outside of academia is doing these. Outpatient billing is already terrible and demands high volume to meet inpatient levels. You just cant burn through 4 post-ICU visits properly in an hour the way you can bread and butter stuff. It is an 'untapped frontier' the same way there isnt a fibromyalgia or chronic back pain clinic network

 

[WheezyBaby]

Anybody involved in these, or have any thoughts? I never gave much thought to them until I started talking to people who I remembered from the unit who I felt "did well" (recovered, went to rehab, went home, back at work). The mental and physical impact that critical illness still has on them (and probably will for life) I was truly stunned to see. Nightmares, PTSD, weakness, fatigue etc.. I started to wonder what kind of a life we're saving these people for? Then I heard that some places have post-icu clinics, staffed by intensivists, psychiatry, PT/OT, pharmacy etc. Sounds to me like a wonderful way to unload their PCP who doesn't have the time to sort through everything that has happened and what meds they're now on and which specialists they need to see first...

I'm wondering what your thoughts are on the matter. I've definitely met a fair share of intensivists who turn their nose up at these clinics. I can understand that, but I don't know that they fully appreciate how broken people can be when they leave the ICU, even under the best of circumstances. Not saying we all need to run clinics, but it seems like a good way to augment a career, or even slowly shift into these clinics as the years and years of ICU start to wear on us.

Lastly, can we compile a quick list of places that have these clinics? I'd like to read more about their approaches. So far all I know is:
Michigan
Vanderbilt
Mayo
Cleveland Clinic
UPMC

IU was pioneering in this area as well. I'm not an expert in the area by any means, and PICS is very real, but based on my own literature review the data is not very robust to support them, particularly given the amount of resources that have to be invested. There seems to be somewhat of an evolving shift to trial less resource intensive interventions

 

[WheezyBaby]

This is the real reason why nobody outside of academia is doing these. Outpatient billing is already terrible and demands high volume to meet inpatient levels. You just cant burn through 4 post-ICU visits properly in an hour the way you can bread and butter stuff. It is an 'untapped frontier' the same way there isnt a fibromyalgia or chronic back pain clinic network

Also agree with this to a degree, I think there needs to be demonstration that these programs are cost-saving to get payer-investment and get any kind of feasibility outside of research-based and conventional billing-based funding

 

[engineeredout]

Cooper Hospital Camden NJ hosts what is more of a post icu support group- patients and families get to sit around and talk with others going through similar stuff.

No it’s not a money maker, but could really be of benefit to a lot of people, especially families, going through this mess.

 

[WheezyBaby]

2 good articles in the area for anyone interested

Critical Care Follow-up Clinics: A Scoping Review of Interventions and Outcomes - PubMed

Intensive care unit survivor follow-up clinics provide a venue for further interdisciplinary intervention research that could lead to better health outcomes for ICU survivors.

www.ncbi.nlm.nih.gov

Learning from aftercare to improve acute care - Intensive Care Medicine

link.springer.com

 

[Colorado outliers]

2 good articles in the area for anyone interested

Critical Care Follow-up Clinics: A Scoping Review of Interventions and Outcomes - PubMed

Intensive care unit survivor follow-up clinics provide a venue for further interdisciplinary intervention research that could lead to better health outcomes for ICU survivors.

www.ncbi.nlm.nih.gov

Learning from aftercare to improve acute care - Intensive Care Medicine

link.springer.com

Thanks for the links.

As others have mentioned these clinics are not profitable and as far as I can tell generally unproven in their benefit to patients. It would seem that they could help, but unless they are seeing patients more often (like every week after discharge for a few months, which wouldn't be practical) I doubt they will do much.
Currently they exist more as opportunities for research and grant $$$ than any practical purpose.

The emergence of these clinics just highlights the difficulties patients with complex medical conditions have in getting adequate post-hospital care, and the fragmentation between inpatient and outpatient care, IMO. I don't believe a post-ICU clinic in its current form is a good solution. A good 'primary care home' would probably actually do more for these patients.

 

[BigRedBeta]

Thanks for the links.

The emergence of these clinics just highlights the difficulties patients with complex medical conditions have in getting adequate post-hospital care, and the fragmentation between inpatient and outpatient care, IMO. I don't believe a post-ICU clinic in its current form is a good solution. A good 'primary care home' would probably actually do more for these patients.

All very true.

That said, I think the opportunity of these clinics lays not in them being offered at every hospital with an ICU, but in finding things to optimize in the Unit that sets patients up for a better life once they've left the hospital. Then you're looking more for the academic medical centers to define the standard, prove it works, and affect what everyone else does years later. That would be easily far more cost effective, however, I'm not sure the powers that be will ever approach it that way.

If such clinics were ever to bear anything useful it would be because of picking very specific patient populations and wisely chosen outcomes - and most ideally, it would relate towards care provided while in the ICU, not coordination of outpatient care. In the NICU, it was choosing neurodevelopmental outcomes and being able to aggregate much larger populations at considerable timescales (1,3,5, even 10 years later) that provided the important insights into optimizing care while in the unit. But most preemies only fall into about 6 different diagnoses, all of which are related to prematurity, so it's a helluva lot easier to throw them all into the data and see what kicks out.

Even if something useful was found in these clinics I believe there are are also biases common to adult medicine that would limit implementation/acceptance of the findings - for example how small sample sizes from single center studies would be viewed methodologically (which pretty much is all that pediatrics research gets), or the use of "soft outcomes" as primary aims (seems like a great many people don't care about anything unless it decreases mortality or readmissions).