What happens after my patient leaves the ICU? Phil Verhoef

Evaluated 109 patients at 3, 6, 12 months post discharge Median LOS was 25 days, age was 45, APACHE was 23 Lost 18% of baseline weight at discharge which they slowly regained over the year but weren’t back to baseline at 12m DLCO was still low at 12 months (63, 70, 72%) 6 min walk at 3 months was 281m, 422 at 12m What predicted better outcome? Not getting steroids, not getting another illness in the unit, and rapid improvement.

AJRCCM, 2005 74 patients. Mean intubation: 28d, LOS: 29d, APACHE 18.1 Used neuropsych testing and QOL questionnaires 73% with neurocognitive sequelae at discharge, 46% at 1 year, and 47% at 2 years. At 1 year? 16% with depression, 24% with anxiety At 2 years, 23% with depression, 23% with anxiety

Enrolled 300 patients (median age 60.5, LOS is 6.7d) Prospective cohort Enrolled 300 patients (median age 60.5, LOS is 6.7d) Physical QOL was down at 3 months, but rose back to baseline at 12 months, then fell again from 2.5-5 years During the 5 years after ICU, the QALY were significantly lower than for the population Uses the EQ5D tool which can then be used to measure Quality Adjusted Life Years, or QALYs QALYs are sort of a surrogate for disease burden and is used (esp in the UK) to determine if a therapy should be covered, ie, what’s it’s cost-effectiveness? How many “QALYS” of benefit do you get for every dollar spent?

Definition? PICS, derived in 2010 Post Intensive Care Syndrome: ‘new or worsening impairments in physical, cognitive or mental health status arising after critical illness and persisting beyond acute care hospitalization”, Physical problems: ICU-acquired weakness, dysphagia, cachexia, organ dysfunction, chronic pain, sexual dysfunction Mental health problems: depression, anxiety, PTSD Neurocognitive problems: cognitive impairment, delirium

So what do you do, while they’re inpatient? Early physical therapy while they’re in the hospital Avoid corticosteroids (if possible?) Avoid benzodiazepines for sedation (and maybe avoid propofol… why?) ICU diaries (there’s actually some evidence for this!)

What do you do, post-discharge? Published Nov 2017, in PLOSone QI project in Scotland where 49 patients were discharged to a 5 week, peer-supported rehab program including pharmacy, physical therapy, nursing, medical care, and psychology Measured EQ5D and assessed self-efficacy with questionnaires and compared to a historical control Some metrics did improve (but the study was too small to draw any real significant conclusions)

What do you do, post-discharge? From Jan 2018 Screen for common, treatable impairments after sepsis Functional disability, with a PT/OT referral Swallowing impairment, with a speech referral Mental health, with screening and referral for depression/anxiety Review and adjust long term medications Errors of omission occur in 10-25% of patients, and errors of commission occur in 1-25%... Confirm that the long term meds they’re on are appropriate DC hospital meds that they don’t still need (PPIs, inahlers) Adjust doses for new changes in BMI, renal, or cardiac function Anticipate and mitigate risk for causes of health deterioration Readmissions happen primarily for sepsis, pneumonia, UTI, CHF, AKI, or COPD… pay special attention to the management of those diseases